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V 


SURGERY  AND  SOCIETY 


BY  THE  SAME  AUTHOR 

worry:  the  disease  of  the  age 
evolution:  the  master  key 

health,  strength  and  happiness 

parenthood  and  race  culture 
woman  and  womanhood 

ETC.,    ETC. 


SURGERY  AND  SOCIETY 

A 
TRIBUTE  TO  LISTERISM. 


BY 

C.  W.  SALEEBY,  M.D.,  F.R.S.E. 

Fellow  of  the  Obstetrical  Society  of  Edinburgh;  formerly  Resident  Physician 
Royal  Infirmary  and  Resident  Surgeon  Maternity  Hospital  of  Edinburgh. 


NEW  YORK 

MOFFAT,  YARD  AND  COMPANY 

1912 


Copyright  1912,  by 

Moffat,  Yard  and  Company 

New  York 


All  Rights  Reserved 


NOTE 

The  motives  and  purposes  of  this  volume  are  in  part  per- 
sonal, in  part  public.  The  personal  motives  are  gratitude 
for  great  benefit  lately  received  from  surgery  and  desire  to 
make  some  reparation  for  too  hard  words  spoken  of  the 
surgical  profession  some  years  ago  under  stress  of  intense  and 
honest  conviction.  The  public  motives  are,  to  state  the  case 
for  surgery  and  therefore  for  science,  in  modern  society ;  once 
more  to  challenge  the  anti-Vivisectionists ;  to  demand  the  first 
of  what  I  call  the  Rights  of  Mothers,  from  my  standpoint 
as  a  Eugenist;  to  state  the  women's  share  in  this  most  be- 
neficent of  human  achievements,  and  to  discuss  the  place  and 
needs  of  surgery  in  the  new  experiments  for  national  control 
of  disease,  towards  which  modern  politics  is  tending. 


282484 


CONTENTS 

CHAPTER  PAGE 

I  INTRODUCTION i 

II  SURGERY  AS  IT  WAS  —  ANESTHESIA      .     .  28 

III  MICROBES 38 

IV  PASTEUR  THE  FORERUNNER 52 

V  LISTER  INTERVENES 66 

VI  THE  CRITICS,  ANTI-VIVISECTIONISTS,  ETC.    95 

VII  THE     DEVELOPMENT  — ANTISEPTIC     AND 

ASCEPTIC  METHODS 113 

VIII  LISTERISM  AND  MOTHERHOOD 134 

IX  LISTERISM  AND  WAR 171 

X  SURGERY  AS  IT  IS  ....   • 195 

XI  THE  RECORD  OF  A  CASE 256 

XII  SURGERY  AND  ALCOHOL 272 

XIII  MISS  FLORENCE  NIGHTINGALE 301 

XIV  THE  MODERN  NURSE 317 

XV  THE  ABUSE  OF  LISTERISM 334 

XVI    THE  PROVISION  OF  LISTERISM 349 

XVII    THE  PROMISE  OF  THE  FUTURE 376 


Vll 


SURGERY  AND  SOCIETY 

CHAPTER  I 

INTRODUCTION 

The  lack,  as  late  as  the  second  decade  of  the  twenti- 
eth century,  of  any  book  devoted  to  the  most  benefi- 
cent achievement  in  the  entire  record  of  science,  is 
not  easily  to  be  credited,  nor  satisfactorily  to  be 
explained.  But  the  fact  and  the  explanation  may 
duly  be  considered  here. 

There  are  to  be  found  inaugural  addresses,  de- 
livered to  medical  students  or  on  other  academic 
occasions;  a  few  magazine  articles;  the  volumes  of 
the  collected  papers  of  Lord  Lister;  the  well-known 
life  of  Pasteur;  and  chapters,  of  course,  in  modern 
surgical  text-books  —  all  dealing  with  one  or  an- 
other aspect  of  our  present  subject.  These,  how- 
ever, are  for  all  practical  purposes  almost  non-exist- 
ent so  far  as  the  general  public  or  the  politician  is 
concerned;  and,  even  taken  together,  they  are  not 
equivalent  to  what  a  complete  statement  of  the  deed 
and  the  modern  need  might  be.  The  uses  of  such 
a  complete  statement  may  be  very  imperfectly  at- 
tained in  the  following  pages,  but  at  least  they  will 
demonstrate  that,  though  the  want  for  such  a  book 
is  by  no  means  "  long-felt,"  it  most  assuredly 
should  have  been,  not  merely  for  the  purposes  of 

i 


2  SURGERY  AND  SOCIETY 

general  culture,  nor  just  appreciation  of  greatness, 
but  because  of  the  many  public  needs  which  are  in- 
volved in  Listerism  and  cannot  be  met  until  public 
opinion  is  acquainted  with  the  facts. 

It  was  with  astonishment  and  incredulity,  some 
years  ago,  when  planning  my  New  Library  of  Medi- 
cines, that  I  failed  to  discover  any  existing  book 
devoted  to  this  subject,  of  which  the  importance  in- 
creases daily  as  the  powers  of  the  surgeon  become 
more  extended.  One  knew  that  such  questions  as 
Infant  Mortality  and  the  Prevention  of  Tuberculosis 
and  the  Hygiene  of  Mind  had  never  been  properly 
dealt  with  in  any  organic  and  complete  manner, 
either  for  the  public  or  the  profession.  Surprising 
though  these  lacuna  were,  they  could  be  understood, 
for  the  daily  preventable  slaughter  of  infants  had  to 
wait  for  attention  until  the  development  of  what 
may  be  called  the  Public  Health  Conscience  in  the 
community  —  and  that  is  scarcely  yet  a  stripling; 
and,  similarly,  the  prevention  of  tuberculosis  could 
not  be  dealt  with  until  the  discovery  of  the  tubercle 
bacillus  and  its  modes  of  transference  from  the  sick 
to  the  sound.  But  though  the  books  of  Sir  George 
Newman  and  Dr.  Newsholme  and  Sir  Thomas 
Clouston  should  doubtless  have  been  written  long  be- 
fore, they  were  not  nearly  so  overdue  as  a  volume 
on  Modern  Surgery,  its  history,  its  powers,  and  its 
place  in  the  State ;  for,  after  all,  however  inadequate 
the  public  consciousness  of  the  fact,  this  mighty  deed, 
to  which  we  are  one  and  all  at  this  hour  incalculably 
indebted,  dates  as  far  back  as  the  later  sixties  of  the 
nineteenth  century  for  its  essential  doing. 


INTRODUCTION  3 

Lord  Lister  himself,  in  a  letter  which  is  a  cher- 
ished possession,  declined  on  the  grounds  of  advanc- 
ing years  the  proposal  to  write  the  book.  The 
Victorian  dignity  and  courtesy  of  his  refusal  were 
sufficient  to  remind  one  of  what  age  he  is  indeed  a 
glory.  Two  or  three  of  my  personal  friends 
amongst  contemporary  surgeons,  refused  on  one 
ground  or  another  —  principally,  perhaps,  because 
they  considered  that,  in  their  hands,  the  knife  was 
mightier  than  the  pen.  Assuming,  at  that  time,  that 
only  a  surgeon  could  suitably  write  the  needed  book, 
I  gave  up,  for  the  nonce,  the  search  for  an  author. 
But  as  the  years  have  passed,  and  medical  and  surgi- 
cal questions  have  more  and  more  taken  on  their 
social  and  national  aspect,  not  least  in  relation  to 
the  urgent,  ominous,  scandalously  neglected  needs  of 
the  nation's  school  children,  as  revealed  by  medical 
inspection,  it  has  seemed  clear,  first,  that  this  book 
must  be  written  forthwith,  the  public  ignorance  of 
the  subject  being  shown  to  be  no  longer  a  defect  in 
culture  merely,  but  a  defect  in  citizenship;  and,  sec- 
ond, that  from  some  points  of  view  there  may  be 
an  advantage  in  the  presentation  of  the  case  by  an 
author  who,  whatever  his  defects,  speaks  of  what 
he  knows  at  first-hand  and  has  lived  with  day  and 
night,  but  does  so  without  any  personal  or  profes- 
sional bias,  not  being  himself  engaged  in  any  form 
of  medical  or  surgical  practice.  His  recollection  of 
the  details  of  surgical  technique  or  of  surgical  anat- 
omy may  very  well  be  neither  too  accurate  nor  too 
precise,  but  these  do  not  concern  anyone  but  the 
operator  as  operator  —  who  is  the  one  person  to 


4  SURGERY  AND  SOCIETY 

whom  these  pages  are  not  addressed,  except  in  so 
far  as  they  deal  with  the  question  of  his  economic 
status  in  society,  with  its  manifold  anomalies,  in- 
justices, and  inefficiencies.  On  the  other  hand,  it 
may  well  be  that  a  writer  who  could  only  injure 
himself  by  overstatement  of  the  case  for  surgery, 
or  by  any  misdirection  of  the  public,  may  gain  a 
wider  and  more  patient  hearing  than  might  possibly 
be  accorded  even  to  an  illustrious  and  fair-minded 
surgeon. 

The  public  advocacy  of  new  ideas  demands  end- 
less reiteration.  The  repetition  must  be  so  continu- 
ous, if  possible  varied  and  long-maintained,  that,  at 
last,  by  the  action  of  certain  psychological  sequences 
which  are  well  worthy  of  study  for  their  bearing 
upon  national  policy  and  conduct,  people  begin  to 
suppose  that  these  ideas  and  arguments  are  their 
own,  and  that  the  advocate  is  a  platitudinarian.  It 
is  only  when,  having  long  thought  him  mad,  they 
think  him  dull,  that  he  may  congratulate  himself  on 
having  done  his  work.  On  certain  primary  aspects 
of  Eugenics  or  Race-Culture,  to  which  this  pen  and 
voice  have  long  been  dedicated,  it  really  looks  as  if 
the  public  were  won  and  even  the  politicians  must 
follow.  It  therefore  seems  permissible  and  oppor- 
tune, lest  much  nagging  at  the  public  ear  make  even 
the  enthusiast  weary,  that  he  should  turn  somewhat 
aside  for  a  while  in  order  to  deal  with  a  subject 
which  urgently  demands  treatment,  and  without  the 
due  appreciation  of  which  even  Eugenics  must  lose 
much  of  its  value. 

So  much  may  suffice,  perhaps,  for  stating  the  fact 


INTRODUCTION  5 

that  this  book  still  needs  to  be  written,  and  the  cir- 
cumstances which  have  led  up  to  the  present  under- 
taking. But  something  now  falls  to  be  said  in  ref- 
erence to  what  we  began  by  stating  —  that  no 
satisfactory  explanation  is  forthcoming  for  the  ab- 
sence from  our  libraries  of  any  book  devoted  to  this 
subject. 

It  is  not  that  the  writing  and  publishing  of  books 
is  almost  wholly  a  matter  of  private  enterprise, 
utterly  unco-ordinated  and  tragically  dominated  by 
the  public  demand.  For  anyone,  however,  who 
holds  books  in  high  esteem  —  even  though  he  may 
not  go  so  far  as  to  believe,  with  Carlyle,  that  the 
real  university  is  a  collection  of  books  —  and  who 
is  convinced  that  it  matters  greatly,  for  private  and 
public  conduct,  what  books  we  have  read  and  what 
we  have  not,  it  seems  a  question  worthy  of  discus- 
sion, at  some  other  time,  whether  the  writing  and 
reading  of  books  that  deal  with  the  world  and  with 
knowledge  as  they  are  and  will  be,  do  not  demand 
the  employment  of  as  much  organized  thought  as 
is  now  devoted  to  the  study  of  books  which  deal 
with  the  world  and  knowledge  as  they  were.  We 
have  at  present  the  extraordinary  situation  that  the 
public,  young,  middle-aged,  or  elderly,  derives  its 
ideas  and  its  information  upon  all  the  scientific  mat- 
ters whence  the  modern  weapons  of  international 
competition  are  forged,  from  the  daily  press  to  the 
practical  exclusion  of  anything  else,  and  without  the 
previous  training  which  would  enable  it  to  judge 
and  to  profit  by  this  means  of  instruction,  with  all 
its  risks  and  randomness.     Now  what  may  be  the 


6  SURGERY  AND  SOCIETY 

success  of  educated  democracy,  it  remains  for  the 
future  to  discover,  the  educated  democracies  of  to- 
day being  neither  really  educated  nor  really  demo- 
cratic, with  the  possible  exception  of  Switzerland. 
But  assuredly  uneducated  democracy  will  not  work, 
now  or  at  any  other  time ;  and  it  has  no  chance  what- 
ever, in  international  competition  with  an  expert 
bureaucracy,  such  as  is  now  guiding  modern  Ger- 
many to  her  evidently  exalted  destiny.  Plainly, 
therefore,  much  might  well  be  said  on  this  question 
of  our  public  reading,  and  the  character  of  the  pro- 
vision therefor. 

But  whatever  may  be  the  inadequacy  of  private 
enterprise  in  the  provision  of  books,  the  real  ex- 
planation, in  all  its  unsatisfactoriness,  of  the  public 
ignorance  on  this  question  now  under  discussion,  and 
a  thousand  others,  lies  in  the  national  attitude  to- 
wards science,  the  national  preference  for  quick 
returns,  and  the  cash-estimate  of  all  human  affairs. 
If  ever  a  country  produced  pioneers  in  knowledge, 
England  has  done  so.  Bacon,  Locke,  Newton,  Har- 
vey, Spencer,  Darwin,  Kelvin,  Lister  —  these,  set 
down  at  random,  would  suffice  to  extort  the  admira- 
tion of  the  world.  But  the  land  which  produced 
these  men  is  also  a  nation  of  shopkeepers,  and  of 
squires,  and  of  belief  in  the  omnipotence  of  sheer 
valour,  and  even  the  partial  insanity  of  any  who 
devote  themselves  to  knowledge  primarily  for  its 
own  sake.  The  visible  and  the  concrete  we  can  ac- 
cept: but  even  the  visible  must  be  visible  to  the 
naked  eye:  microscopic  is  semi-mythical.  Thus,  in 
the  matter  of  health,  we  have  long  led,  and  still  lead 


INTRODUCTION  7 

the  world  in  primary  sanitation.  Drains  and 
water-supply  we  can  credit  and  take  to;  the  appeal 
to  theoretical  considerations  or  to  the  invisible  in 
general  is  not  required,  and  public  opinion  requires 
no  winning  over :  at  least  we  have  noses. 

But  theoretical  considerations  are  ever  becoming 
more  and  more  important  in  the  advance  of  knowl- 
edge and  practice.  In  general,  it  is  fair  to  say  that 
the  day  of  empiricism  is  past.  We  can  no  longer 
afford  to  "  muddle  through."  The  inventions  and 
achievements  of  to-day,  whether  in  such  a  practical 
realm  as  that  of  applied  electricity,  or  in  the  treat- 
ment of  disease,  are  most  definitely  not  the  results 
of  happy  chance,  of  guesswork,  of  intuition,  or  of 
sheer  patience.  They  require  and  depend  upon  the 
theoretical  considerations  which  strike  the  popular 
mind  as  unreal  or  unimportant.  This  is  true  of 
surgery  itself.  The  word  surgery  simply  and  liter- 
ally means  handwork.  The  physician  was  the  stu- 
dent of  Nature,  as  his  name  suggests ;  the  chirurgeon 
was  the  "  manual  labourer  "  in  a  Greek  dress  —  ob- 
viously a  practical  person.  But  the  mere  literal 
"  surgery  "  is  the  very  least  of  modern  surgery,  and 
will  be  even  less  important  in  the  surgery  of  the 
future.  Uses  will  always  remain  for  dexterity,  and 
advantages  can  still  be  demonstrated  in  some  meas- 
ure for  celerity.  But  the  difference  between  the 
surgery  of  to-day,  the  beneficent  science  which  daily 
saves  countless  lives,  and  the  surgery  that  was  in  the 
world  until  Lord  Lister  dawned,  in  no  degree  what- 
ever depends  upon  any  advance  in  surgery  proper 
—  that  is,  in  the  manipulations,  the  skill  and  speed, 


8  SURGERY  AND  SOCIETY 

of  the  operator.  This  colossal  revolution  in  prac- 
tice entirely  depends  upon  theoretical  calculations; 
and  it  may  well  be  doubted  whether,  in  sheer  oper- 
ative skill,  the  surgeons  of  half  a  century  ago  could 
be  equalled,  much  less  surpassed  to-day.  As  oper- 
ative skill  was  then  everything,  naturally  it  was  de- 
veloped to  the  utmost.  It  is  so  much  less  than 
everything  to-day  that  the  modern  Listerian  nurse, 
who  has  never  had  a  knife  in  her  hand,  is  a  vastly 
better  surgeon,  in  a  very  true  sense,  than  the  greatest 
practitioners  of  half  a  century  ago,  as  we  can  realise 
at  once  if  we  choose  to  compare  their  respective 
methods  of  dressing  any  wound  whatever.  The 
vital  difference  entirely  depends  upon  theoretical 
considerations:  upon  abstract  conclusions,  reached 
for  their  own  sake,  by  processes  of  reasoning,  veri- 
fied by  experiment,  and  unrelated  altogether  to  the 
existence  of  such  a  thing  as  a  knife  at  all. 

The  national  neglect  of  science  is  a  national  men- 
ace, as  the  responsible  leaders  of  the  scientific  world 
have  again  and  again  declared  from  the  Presiden- 
tial Chair  of  the  British  Association  and  elsewhere. 
Our  practical  genius  is  so  great  that,  in  certain  di- 
rections, our  scepticism  of  science  as  such  seems  to 
do  us  little  harm.  It  is  declared  that  no  single 
invention  of  the  first  rank  in  engineering  or  elec- 
tricity stands  to  our  credit  for  many  years  past. 
But  notwithstanding  our  defects  in  this  regard,  and 
such  obstacles  as  the  law  which  prescribed  a  man 
with  a  red  flag  in  front  of  every  mechanically-pro- 
pelled vehicle,  we  constantly  contrive  to  lead  the 
world,  it  would  seem,  in  the  mechanical  arts. 


INTRODUCTION  9 

As  I  have  often  declared,  however,  the  culture  of 
the  racial  life  is  the  vital  industry  of  any  people; 
and  if  this  be  true  universally,  as  it  is,  even  more 
abundantly  than  elsewhere  is  it  true  of  us,  with  our 
world-wide  Empire,  our  practically  uninhabited 
Continent  "  down  under,"  our  small  and  rapidly  fall- 
ing birth-rate,  our  addition  of  only  one  child  to  our 
numbers  for  every  two  in  Germany,  and,  lastly,  the 
appalling  needs  of  our  next  generation  as  revealed 
by  medical  inspection  of  school  children.  Now 
though  any  man  may  make  a  useful  and  honourable 
and  beloved  family  doctor  who  is  destitute  of  science 
altogether,  the  making  and  maintaining  of  a  healthy 
population  under  the  conditions  of  urban  aggrega- 
tion can  be  achieved  by  science  or  not  at  all.  The 
science  of  life  underlies  the  life  of  nations  as  it 
underlies  the  lives  of  individuals.  Both  alike,  live 
or  die  according  to  their  consonance  with  the  laws 
of  life,  whether  those  laws  happen  to  be  known  or 
unknown.  It  is  these  laws  of  which  we  see  the 
consequences  in  our  yearly  more  unsatisfactory  re- 
cruits, and  in  the  countless  numbers  of  children  who 
need  surgical  intervention  in  England  at  this  hour, 
if  they  are  to  be  saved  for  themselves  and  for 
her. 

And  it  was  the  laws  of  life  which  Pasteur  and  Lis- 
ter elucidated,  and  which  have  transformed  the  prac- 
tice of  ages.  The  tree  of  life  and  the  tree  of  knowl- 
edge, which  grew  side  by  side  in  Eden,  and  the  tree 
of  life,  whose  fruit  and  leaves  were  for  the  healing 
of  the  nations  in  the  Holy  City,  are  one :  as  we  must 
realise  if  we  are  to  make  our  cities  and  citizens  holy 


io  SURGERY  AND  SOCIETY 

and  healthy  —  which  are  two  forms  of  the  same 
word. 

Let  this  introductory  chapter  end,  therefore,  with 
two  appeals,  or  at  least  with  the  statement  of  two 
definite  needs  of  our  own  time  in  this  matter  of  vital 
knowledge.  First  as  to  its  gaining,  and  second  as 
to  its  giving. 

In  order  that  knowledge  shall  be  gained  the  la- 
bourer must  be  provided  for,  both  as  to  his  personal 
and  his  scientific  needs.  In  every  branch  of  sur- 
gery, from  the  problems  of  cancer  downwards,  there 
is  need  for  more  knowledge.  Only  in  small  and 
accidental  degree  can  this  knowledge  be  now  ob- 
tained by  the  observation  of  the  surgeon  in  the  course 
of  his  work.  The  fundamental  advances  in  the 
chemistry  of  life  and  of  vital  reactions  can  only  be 
made,  under  specially  devised  conditions,  by  spe- 
cially trained  workers  who  set  themselves  to  the 
problems  in  question.  The  extant  provision  for 
such  workers  is  ludicrously  disproportionate  to  the 
need.  Those  who  can,  may  explain  the  fact  that  in 
the  United  States  of  America  the  philanthropic  or 
otherwise-actuated  giver  provides  funds  for  research 
on  the  most  magnificent  scale,  whilst  in  this  country 
only  the  recently  established  Beit  Medical  Fellow- 
ships, founded  by  an  alien,  can  be  quoted  on  any 
comparable  scale.  No  one  can  question  that  it 
must  be  very  pleasant  for  the  kind-hearted  to  reflect 
that  there  is  somewhere  a  hospital  bed  or  an  out- 
patient department,  daily  doing  the  work  of  healing, 
which  they  have  endowed.  But,  if  only  they  could 
be  made  better  acquainted  with  the  history  of  the 


INTRODUCTION  n 

healing  art,  they  would  see  that  provision  for  gen- 
uine research  was  certain,  in  the  long  run  —  not  nec- 
essarily so  very  long  —  to  do  far  more  for  human 
health  and  happiness  than  the  generosity  which 
seems,  at  first  sight,  impossible  to  direct  more 
wisely.  Would  that  one  could  bring  to  the  notice  of 
the  charitable  and  wealthy  the  profound  words  of 
Ruskin,  which  apply  in  such  full  measure  to  the 
present  argument:  — 

".  .  .  it  is  one  of  the  appointed  conditions 
of  the  labour  of  man  that  in  proportion  to  the  time 
between  the  seed-sowing  and  the  harvest  is  the 
fulness  of  fruit,  and  that  generally  therefore  the 
further  off  we  believe  our  aim,  and  the  less  we 
desire  to  be  ourselves  the  witnesses  of  what  we 
have  laboured  for,  the  more  wide  and  rich  will 
be  the  measure  of  our  success." 

It  is  by  no  means  to  be  supposed  that  the  post 
makes  the  researcher,  or  that  the  number  of  those 
who  would  apply  for  such  posts  is  the  number  of 
those  fit  to  fill  them.  Many  are  called  but  few  are 
chosen.  The  tragedy  is  our  present  mishandling  of 
those  few.  One  man  can  research,  another  can 
teach.  The  two  capacities  may  be  united,  but  there 
is  no  necessary  connexion  between  them.  The  born 
researcher  is  probably  much  rarer  than  the  born 
teacher;  and  he  is  indispensable.  Frequently  he 
chances  to  be  almost  inarticulate.  Now  the  English 
method  of  rewarding  a  man  for  research  is  to  give 
him  a  post  as  a  teacher.     Very  likely  he  is  not  the 


12  SURGERY  AND  SOCIETY 

best  teacher  available,  even  if  he  be  able  to  teach  at 
all;  and  the  best  teacher,  who  may  have  great  ca- 
pacity of  thought  and  illustration,  but  none  for  re- 
search, may  be  left  in  the  cold.  Worse  than  this, 
the  researcher  is  commonly  sterilised  by  his  reward. 
Often,  alas,  his  success  means  the  disappearance  of 
the  external  inducement  to  work  which  all  but  the 
very  fewest  require.  There  is  no  end  to  the  list  of 
those  who  have  done  good  work,  gained  a  post,  and 
never  done  any  more.  But  even  if  the  man  desires 
to  work  he  has  his  teaching  duties  to  discharge,  and 
these  take  up,  with  incalculably  less  profit  to  the 
community,  the  time  and  energy  that  should  be  de- 
voted to  the  task  for  which  he  is  fitted.  The  whole 
system  is  fundamentally  wrong,  and  sounds  as  if  it 
might  have  had  its  origin  in  the  virgin  nescience  of 
some  past  "  Statesman,"  so-called.  The  proper  re- 
ward for  the  man  who  is  a  born  researcher  is  to  give 
him  better  opportunities  for  research  and  due  hon- 
our for  the  work  he  does.  These  opportunities  will 
mean  not  merely  a  good  stipend  —  something,  say, 
comparable  to  the  salary  of  a  superior  clerk,  society 
journalist,  or  second-rate  comedian  —  not  merely 
the  provision  of  apparatus  and  funds  for  experi- 
mental research  upon  the  lower  animals,  but,  above 
all,  opportunities  for  attracting,  directing,  and  in- 
spiring those  who  are  to  come  after  him. 

Internecine  jealousy  still  postpones  the  establish- 
ment in  London  of  an  Institute  of  the  Medical  Sci- 
ences, towards  which  a  promising  start  was  made 
a  few  years  ago.  London  is  the  home  of  many 
distinguished  practitioners  of  the  medical  arts.     It 


INTRODUCTION  13 

is  not  a  great  centre  of  medical  and  surgical  science. 
Nor  can  it  become  so  until  our  notions  of  the  relative 
importance  of  theory  and  practice,  and  our  provision 
and  reward  of  them  in  proportion  thereto,  have  un- 
dergone fundamental  revision.  And  if  anyone 
should  suppose  that  this  is  casual  or  unconsidered 
criticism,  unmerited  by  the  facts  of  the  case,  let  him 
consider  the  circumstances  and  history  of  the  great- 
est centre  of  physics  in  this  country,  the  Cavendish 
Laboratory  of  Cambridge.  The  student  of  physics 
knows  the  facts;  and  the  recent  publication  of  a 
volume  to  commemorate  the  twenty-fifth  year  of  Sir 
J.  J.  Thomson's  tenure  of  his  post  should  have  in- 
formed a  larger  section  of  the  thoughtful  public. 
The  feature  of  that  Laboratory  is  that  it  is  the  home 
of  an  illustrious  man,  whose  school,  there  founded 
and  maintained,  leads  the  world  in  its  great  branches 
of  inquiry,  and  bids  fair  to  continue  to  do  so,  whilst 
the  genius  and  patience  and  energy  of  "  J.  J."  re- 
main there  to  attract  the  few  best-endowed  young 
men  of  each  decade. 

It  is  probably  impossible  to  over-estimate  the  sig- 
nificance and  the  ultimate  practical  importance  of 
the  work  done  at  the  Cavendish  Laboratory.  Per- 
fectly conceivable  is  the  speculation  that  the  study 
of  electrical  and  molecular  forces,  and  of  physical 
chemistry,  there  prosecuted,  might  give  us  the  un- 
derstanding of  the  behaviour  of  the  malignant  cell, 
which  might  instantly  supersede  the  whole  surgery 
of  cancer.  But,  however  highly  we  rate  the  work 
of  that  wonderful  place,  we  cannot  question  that  it 
should   have   its   compeer  in   the  biological  realm. 


i4  SURGERY  AND  SOCIETY 

The  days  of  "  natural  history,"  of  field  botany,  and 
of  the  descriptive  systematist  will  doubtless  never  be 
past;  but  in  our  age  we  have  a  new  science,  well 
named  biology,  which  must  sooner  than  later  assume 
the  experimental  form  which  is  indispensable  for 
the  physical  sciences.  Men  of  genius,  specialised  in 
this  direction  no  less  definitely  than  Sir  Joseph 
Thomson  in  his,  may  now  exist  in  England,  and 
doubtless  do;  but  the  right  field  for  them  is  not 
forthcoming.  The  mutual  jealousy  of  the  hospitals, 
which  has  for  many  years  served  to  reduce  the  num- 
ber of  medical  students  in  what  should  evidently  be, 
having  regard  to  its  wealth  and  its  unexampled 
abundance  of  clinical  material,  the  greatest  centre 
of  medical  science  in  the  world,  has  prevented  and 
still  prevents  London  from  possessing  what,  but  for 
this  despicable  and  suicidal  policy,  might  well  be  the 
due  parallel  in  biological  medicine  ^i  the  Cavendish 
Laboratory. 

Perhaps  enough  will  have  been  said  to  show  that 
the  medical  and  surgical  profession  is  really  in  an 
anomalous  and  untenable  position  to-day.  Its  mem- 
bers seek  to  exist  by  their  private  and  individual 
services  to  individuals,  as  the  barrister  or  solicitor 
does.  But  the  profession  of  healing  has  another 
function  to  which  that  of  law  offers  no  parallel.  It 
has  a  branch  of  science  in  its  keeping;  and  the  time 
has  very  nearly  if  not  wholly  passed  when  a  prac- 
titioner such  as  was  Joseph  Lister  can,  simultane- 
ously with  the  practice  of  his  profession,  institute 
biological  experiments,  which  transform  one  of  the 
major  facts  of  human  life.     The  public  and  the 


INTRODUCTION  15 

philanthropic  and  the  State  must  learn  that  the  time 
has  come  when  competent  men  must  be  supported 
in  decency  and  certainty  whilst  they  discover  the 
natural  facts  and  laws  upon  which  the  future  prog- 
ress of  medicine  and  surgery  depends.  Those  prac- 
tical arts  depend  upon  certain  sciences  for  the  ade- 
quate prosecution  of  which  there  is  no  sufficient  pro- 
vision in  this  country.  The  charitable  may  be  as- 
sured that,  if  they  will  be  patient  and  faithful,  their 
beneficence  will  be  proved  more  beneficent  if  it  be 
devoted  to  the  prosecution  of  research  than  if  it  be 
content  with  immediate  results. 

And,  finally,  it  must  be  insisted  that  the  business 
of  the  doctor  is  not  only  to  learn  but  also  to  teach. 
Literally,  the  doctor  is  a  teacher;  actually,  amongst 
ourselves  to-day,  he  is  almost  anything  but  that. 
Yet,  already,  just  and  necessary  as  is  the  demand 
for  more  knowledge  and  the  means  thereto,  we  pos- 
sess a  great  mass  of  assured  knowledge  in  medical 
and  surgical  matters  which  it  is  the  duty  of  the  pro- 
fession as  a  whole  and  by  means  of  its  individual 
members  to  force  upon  the  consciousness  of  the  com- 
munity. We  have  as  yet,  to  take  the  education  of 
the  governing  powers,  no  Ministry  of  Health,  nor 
even  any  adequate  status  for  the  medical  sciences  in 
the  Local  Government  Board.  We  have  only  just 
admitted  these  sciences  to  the  Board  of  Education, 
a  propos  that  medical  inspection  of  school  children 
which  has  already  revealed  more  surgical  need  than 
we  have  surgeons  existing  to  supply.  We  have  far 
too  few  medical  members  of  Parliament;  though  that 
grave  defect  may  be  remedied  when,  as  appears  pos- 


16  SURGERY  AND  SOCIETY 

sible,  the  House  of  Gramophones  is  transformed 
and  becomes  a  House  of  Men.  In  the  national 
services  we  still  have  an  abundance  and  to  spare  of 
the  spirit  represented  by  the  remark  of  a  famous 
Field-Marshal,  still  living,  that  "  Medical  advice  is 
a  very  good  thing  —  when  it  is  asked  for." 

Similar  criticism  is  applicable  when  we  ask  to 
what  extent  the  doctor  is  literally  a  doctor  of  public 
opinion  in  general.  The  profession  has  not  real- 
ised its  true  dignity  as  in  major  degree  the  guar- 
dian of  the  body-politic.  The  conditions  of  medical 
etiquette  and  professional  jealousy  severely  limit  the 
activities  of  those  who  might  otherwise  devote  them- 
selves to  the  literal  business  of  doctoring.  Coming 
to  London  ten  years  ago,  with  the  intention  of  serv- 
ing terms  in  certain  special  hospitals  for  the  pur- 
poses of  practice,  the  present  writer,  full  of  en- 
thusiasm for  the  great  benefactors  of  mankind  whose 
names  had  been  daily  in  his  ears  in  Edinburgh,  was 
astounded  and  horrified  to  be  asked  by  intelligent 
and  cultured  people,  thoroughly  interested  in  and 
an  courant  with  the  affairs  of  the  time,  such  ques- 
tions as  "Who  is  Lord  Lister?"  It  was  too  out- 
rageous, and  one  set  to  work  to  tell  a  few  people, 
by  means  of  the  public  Press,  and  on  the  few  plat- 
forms then  accessible,  who  Lord  Lister  was,  and  to 
answer  a  number  of  similar  questions.  But  unless 
one  was  content  either  to  be  a  gramophone  —  with- 
out the  Parliamentary  kudos  —  or  else  to  go 
gagged,  it  was  necessary  to  abandon  all  professional 
practice  whatsoever,  and  taking  the  highly  dubious 
step,  as  it  then  was,  I  did  so;  and  thus  am  answerable 


INTRODUCTION  17 

to  no  smaller  body  than  the  public  at  large;  nor 
can  it  be  urged  that  anything  I  write  or  say  is  for 
the  attraction  of  patients.  But  it  is  a  most  unfortu- 
nate and  disastrous  state  of  things  that  those  who 
have  qualified  themselves  in  some  measure  for  the 
task  of  public  instruction  by  means  of  a  prolonged 
and  expensive  education  should  be  practically  barred, 
as  they  are,  from  fulfilling  this  function,  which  I 
believe  to  be  of  the  utmost  value  and  necessity, 
unless  they  can  somehow  contrive  to  live  without 
practising  at  all.  It  will  be  agreed  that  the  public 
Press  now  contains  far  more  medical  news  and  in- 
struction, on  the  whole  most  desirable  and  suitable, 
than  when  I  published  the  many  articles  on  Lister- 
ism  and  infant  mortality,  alcohol,  consumption,  and 
so  forth,  for  which  so  much  criticism  was  forthcom- 
ing. But  vastly  more  remains  to  be  done.  On 
these  vital  matters  we  have  an  instructed  profession 
and  a  public  which  is  ignorant  beyond  belief  —  nec- 
essarily so,  of  course.  The  profession  in  question 
is  just  as  ignorant  of  engineering  or  law  or  philol- 
ogy, and  assuredly  has  no  monopoly  of  ignorance 
or  narrowness.  But  these  many  things  which  it 
does  not  know  are  not  vital,  and  do  not  need  to  be 
known  by  everyone;  whereas  its  special  knowledge 
directly  affects  life,  health,  and  happiness  of  every 
man,  woman,  and  child,  present  and  to  come,  and 
is  of  limitless  potency  in  determining  the  destiny  of 
our  nation  and  our  race.  The  doctor,  then,  should 
be  a  doctor;  and  it  may  well  be  urged  that,  since 
the  State,  by  practically  universal  consent,  regards 
the  business  of  education  as  its  concern,  it  should  un- 


18  SURGERY  AND  SOCIETY 

dertake  the  task  of  national  education  in  these  most 
vital  of  directions.  One  can  vaguely  imagine  the 
existence  of  a  department,  in  some  future  Board  of 
Health,  which  would  concern  itself  with  such  ac- 
tivities as  are  instanced  by  the  French  official  post- 
ers against  alcoholism,  and  with  the  maintenance 
and  direction  of  lectures  to  teachers  and  to  the  mem- 
bers of  the  many  societies  which  concern  themselves 
with  social  well-being.  Under  the  agis  of  a  great 
department  of  State,  disinterested  and  authoritative, 
such  lectures  would  have  the  greatest  influence,  not 
least  upon  the  habits  of  the  people,  which  the  gen- 
eral practitioner,  and  especially  the  "  club  "  doctor, 
can  scarcely  afford  to  criticise. 

To  consider  more  especially  the  matter  of  sur- 
gery, let  us  turn  to  one  more  fact  which  should  alone 
suffice  to  warrant  the  publication  of  the  following 
pages.  As  regards  surgical  operations  in  the  gen- 
eral hospitals,  nothing  can  be  more  important  for 
the  public  welfare  than  that  these  institutions  should 
command  the  confidence  of  the  community;  that  pa- 
tients should  be  willing  to  consult  them  early  —  as, 
for  instance,  in  the  widespread  and  disastrous  mal- 
ady commonly  known  as  surgical  tuberculosis,  which 
attacks  so  many  valuable  joints  and  bones  and 
glands;  that  parents  should  be  eager  and  happy  to 
entrust  their  children  to  the  surgeon's  care  in  such 
cases;  that  the  early  symptoms  of  malignant  dis- 
ease should  bring  the  patient,  before  his  chance  is 
gone,  under  the  surgeon's  eye ;  and  that,  when  opera- 
tion is  recommended,  the  advice  should  be  followed. 
Never  shall  I  forget  the  first  instance  in  my  expe- 


INTRODUCTION  19 

rience  of  refusal  of  operation.  A  girl  whose  foot 
was  riddled  with  tuberculosis  consulted  the  surgeon, 
who  advised  amputation.  The  foot  could  never  by 
any  chance  be  of  any  use  again,  and  it  was  a  source 
of  grave  danger.  The  girl  and  her  father  refused 
to  have  the  operation  performed  because  they  be- 
lieved that  its  object  was  not  curative  but  experi- 
mental. 

For  though  the  profession  does  not  as  yet  under- 
take the  task  of  teaching  the  public  in  these  mat- 
ters, some  of  its  enemies  are  wiser  in  their  genera- 
tion. The  anti-vivisectionists,  above  all,  devote 
unstinted  energy  and  large  funds  very  extensively  to 
the  task  of  attempting  to  undermine  the  public  con- 
fidence in  the  hospitals,  above  all  by  the  argument 
that  the  patients  are  regarded  as  subjects  for  ex- 
perimentation. The  vivisector,  they  say,  warms  to 
his  work,  and  when  he  is  sated  with  the  blood  of 
his  animal  victims  he  only  longs  to  turn  his  knife 
upon  his  fellows.  Thus  to  enter  a  general  hospital, 
more  especially  one  to  which  a  medical  school  with 
a  physiological  laboratory  is  attached,  is  to  submit 
oneself  to  what  is  practically  none  other  than  vivi- 
section of  the  human  subject.  The  fact  that  the 
physiologist  has  quite  enough  to  do  in  his  own  de- 
partment, or  that  the  surgeon  can  safely  acquire  the 
skill  and  knowledge  for  certain  operations  only  by 
first  performing  them  upon  the  lower  animals  — 
such  things  are  left  unsaid  by  these  sincerely  un- 
scrupulous fanatics,  and  by  everyone  else. 

From  1902  until  1906  one  of  the  subjects  to 
which  I  devoted  myself  by  pen  and  voice  was  this 


ao  SURGERY  AND  SOCIETY 

matter  of  vivisection  and  the  asserted  experimenta- 
tion upon  human  beings  in  hospitals;  nor  can  I  re- 
call anyone  else  who  was  doing  that  work  of  public 
education  except  for  the  standard  book  of  Mr. 
Stephen  Paget.  We  now  have,  however,  a  Re- 
search Defence  Society,  which  exactly  conforms,  for 
its  particular  sphere,  to  the  demands  of  the  forego- 
ing pages.  It  is  a  society  primarily  of  medical  men 
who  are  banded  together  not  for  the  gaining  of 
knowledge,  but  for  the  giving  of  it.  By  letters  to 
the  Press,  by  distribution  of  leaflets,  by  posters, 
and  by  popular  lectures,  they  undertake  that  very 
work  for  public  education  on  vital  medical  and  sur- 
gical matters  for  which  I  plead.  But  though  noth- 
ing could  be  better  or  more  useful  in  its  way,  the 
Research  Defence  Society  is  confined  to  meeting 
only  one  need  in  this  matter,  and  is,  in  fact,  none 
other  than  the  response  and  antidote  to  the  long- 
continued  educational  labours  of  the  anti-vivisection- 
ists,  but  for  whom,  as  its  name  suggests,  it  would 
never  have  come  into  being.  Vastly  more  than  this 
is  needed;  but  the  Research  Defence  Society  and 
Mr.  Stephen  Paget,  its  Honorary  Secretary,  will 
have  accomplished  much  more  than  their  immediate 
purpose  if  their  methods  and  their  success  and  the 
evident  need  for  their  existence  can  be  employed  as 
the  models  for  future  organisations,  on  similar  or 
parallel  lines,  which  may  devote  themselves,  with 
adequate  funds,  with  the  prestige  of  well-known 
names  in  association,  and  without  suspicion  of  self- 
interest,  to  a  multitude  of  matters,  such  as  those  al- 
ready alluded  to  in  this  chapter,  wherein  the  public 


INTRODUCTION  21 

education  is  defective,  or  where,  indeed,  a  vast 
amount  of  public  misdirection  by  interested  persons 
is  constantly  going  on. 

There  are,  for  instance,  the  large  numbers  of 
persons  who  daily  hire  the  columns  of  the  Press  in 
order  to  advertise  their  nostrums  for  the  cure  of 
varicocele,  haemorrhoids,  hernia,  adenoids,  nasal  ob- 
struction, and  other  surgical  conditions,  claiming 
that  operation  is  to  be  avoided  as  disastrous,  and  is 
in  any  case  rendered  superfluous  by  their  alternative. 
Now  there  is  no  occasion  whatever  why,  in  this 
age  of  surgical  achievement,  a  living  should  be  ob- 
tainable by  these  persons  for  daily  injury  of  the  pub- 
lic. As  I  am  not  a  surgeon  I  must  necessarily  be 
acquitted  of  any  personal  bias  in  declaring  that  these 
people  are  among  the  vermin  of  society,  thieves  not 
only  of  money  but  of  health  and  of  life,  and  that, 
since  no  educated  community  would  tolerate  them 
for  a  moment,  it  is  the  business  of  those  who  have 
the  knowledge  to  impart  it  by  some  means  or  other. 
The  mere  selling  of  aperients  —  of  which  most 
patent  medicines  consist  —  at  absurdly  high  prices 
is  a  legitimate  and  useful  trade  compared  with  what 
we  are  now  discussing.  As  we  have  seen,  the  Press 
is  now  beginning,  in  its  news  columns,  to  furnish 
some  antidote  to  the  lies  which  appear  in  the  adver- 
tisement columns  of  most  papers;  but  surely  it  would 
be  to  the  public  interest  greatly  to  advance  the  gen- 
eral standard  of  knowledge  in  such  matters. 

Another  case  is  that  of  the  so-called  "  hypnotists," 
"  bloodless  surgeons/'  and  the  like,  who  occasion- 
ally infest  the  lower-class  music  halls.     It  seems  to 


22  SURGERY  AND  SOCIETY 

be  no  one's  business  to  deal  with  these  impostors, 
except  when  they  use  the  letters  M.D.  without  due 
title.  In  1905  I  went  to  the  Holborn  Music  Hall 
for  the  purpose  of  exposing  the  best-known  of  these 
practitioners,  and  the  reading  of  my  article  to  the 
jury  in  the  Judge's  summing-up  at  a  subsequent  law 
case  seems  to  suggest  that  it  may  have  contributed 
to  put  an  end  to  his  noxious  career.  The  number 
of  tuberculous  joints  in  which  this  person  must  have 
set  up  new  mischief  by  his  brutal  and  destructive 
methods  cannot  be  stated;  and  it  is  a  scandalous  re- 
flection on  the  state  of  the  general  intelligence  and 
information  that  such  things  were  ever  permitted  at 
all. 

With  one  other  illustration  of  the  argument  that 
we  need  more  public  knowledge,  this  long  intro- 
ductory chapter  must  draw  to  a  close.  Every  sur- 
geon knows  that  only  a  tiny  minority  of  cases  of 
cancer  are  ever  seen  by  the  surgeon  in  time  for  him 
to  effect  the  radical  cure  which,  in  many  instances, 
would  have  been  possible.  Recent  detailed  study  of 
the  mode  of  spread  of  the  disease  only  throws 
greater  stress  upon  the  all-importance  of  early  op- 
eration. "  They  all  come  too  late !  "  is  the  sur- 
geon's comment,  not  least  upon  the  endless  company 
of  women  suffering  from  cancer  of  the  breast  or 
womb.  But  why  do  they  come  too  late?  Surely 
not  because  they  prefer  to  do  so.  They  know  no 
better,  and  there  is  no  one  to  tell  them.  In  Ger- 
many a  little  has  been  done  in  this  regard  by  means 
of  a  newspaper  campaign.  In  England  it  seemed 
to  me  a   few  years  ago  that  something  might  be 


INTRODUCTION  23 

done,  and  I,  therefore,  asked  a  distinguished  surgeon 
to  contribute  a  volume  on  the  subject  to  the  New 
Library  of  Medicine.  An  admirable  volume  was 
the  result,1  but  I  fear  it  must  have  sadly  disap- 
pointed the  author  and  the  publisher,  for  its  sale 
was  trifling,  though  it  contained  information  and 
advice  of  literally  vital  moment  to  more  than  one- 
tenth  of  the  adult  community.  It  certainly  appears 
to  me  that  some  society  or  organisation  ought  to 
exist,  in  this  Listerian  age,  which  has  for  its  business 
the  instruction  of  the  public  on  this  one  matter  alone, 
so  that  the  means  of  salvation  which,  thanks  to 
modern  surgery,  are  available  in  a  large  proportion 
of  these  cases,  may  be  taken  in  time  by  more  than 
one  in  a  thousand  of  those  whom  this  malady  at- 
tacks. 

Such  an  extension  of  the  benefits  now  offered  by 
surgery  to  the  community  can  never  be  attained, 
however,  until  by  some  means  or  other  the  safety, 
the  comparative  painlessness,  the  enormous  and 
peerless  advantages,  the  ever-widening  scope  of  this 
art,  and  the  high  standard  of  capacity  and  honour 
among  its  leading  practitioners,  are  made  matters 
of  universal  public  knowledge.  For  a  constantly 
increasing  proportion  of  the  community,  which  must 
certainly  be  more  than  one-half  already  —  and  for 
everyone  of  us,  if  we  have  those  whom  we  love  — 
the  time  will  come  when  the  surgeon  can  do  for  us 
what  no  combination  of  other  persons  can.  Such 
being  his  rank  amongst  us,  we  should  hold  him  in 

1  The  Control  of  a  Scourge,  by  C.  P.  Childe,  F.R.C.S.    The  New 
Library  of  Medicine,  Methuen  &  Co. 


24  SURGERY  AND  SOCIETY 

the  highest  confidence,  acquaint  ourselves  with  his 
powers,  avail  ourselves  of  them  in  due  season,  facili- 
tate his  work,  and  ensure  his  surpassing  in  years  to 
come  by  means  of  provision  for  the  gaining  of  fur- 
ther knowledge. 

It  is  as  a  humble  effort  towards  these  ends,  and 
in  gratitude  for  personal  benefit  received,  that  this 
book  has  been  written.  And  perhaps  a  single  illus- 
tration will  suffice  to  show  that  its  praise  of  a  great 
man  is  not  superfluous  —  no,  not  in  his  own  coun- 
try. Recently  a  Parisian  paper,  and  one  of  our 
own,  held  polls  of  their  readers,  in  order  to  ascer- 
tain who  were  considered  the  greatest  men  —  in  the 
first  case,  of  all  that  France  has  produced,  and  in 
the  second,  of  our  living  countrymen.  The  French 
electorate  voted  for  Pasteur,  the  greatest  benefactor 
of  mankind  hitherto,  and  he  upon  whose  shoulders 
Lord  Lister  stood  when  he  discerned  the  possibilities 
of  modern  surgery.  It  was  indeed  a  just  choice,  re- 
flecting some  credit  upon  those  who  made  it.  They 
might  have  voted  for  the  greatest  slayer  in  history, 
but  preferred  the  greatest  saviour. 

But  observe  what  was  the  choice  of  the  readers 
of  the  English  paper.  He  was  a  politician,  at  that 
time  the  idol  of  the  crowd.  His  name  dominated 
all  others  for  the  crowds  that  awaited  election  re- 
sults in  1906;  it  scarcely  raised  a  response  in  19 10. 
But  half  a  dozen  years  ago  he  was  ranked  as  the 
greatest  living  Englishman:  Lord  Kelvin,  and  Mr. 
Alfred  Russel  Wallace,  and  George  Meredith,  and 
Herbert  Spencer,  and  Lord  Lister  were  then  still 
with  us.     Such   were   the   riches   from   which    the 


INTRODUCTION  25 

many  —  nor  by  any  means  the  lowest  of  the  many 
—  were  asked  to  choose :  inventor,  interpreter,  seer, 
philosopher,  and  saviour;  and  they  chose  a  politi- 
cian. 

In  order  to  be  saved  it  is  necessary  that  hero- 
worship  shall  flourish;  but  it  is  essential  that  the 
heroes  shall  be  heroes  indeed.  For  though  it  may 
be  evil  to  worship  no  gods,  it  is  surely  worse  to 
worship  false  ones.  And  if  national  education  is 
to  be  what  it  purports  to  be,  indeed,  it  must  ensure 
that  our  choice  of  ideas  and  ideals  and  heroes  shall 
be  high  and  wise  and  discriminating.  The  nation 
which  could  anticipate  the  verdict  of  posterity  upon 
its  prominent  men  would  be  an  educated  and  happy 
nation  indeed.  In  some  cases  it  is  not  necessary  to 
wait  for  posterity;  less  than  a  lustrum1  may  suffice 
to  overturn  a  popular  idol.  But  how  comes  it,  then, 
that  whereas  our  French  neighbors  chose  Pasteur, 
our  compatriots  chose  a  politician?  His  name 
matters  not  at  all;  had  he  been  Salisbury  or  Glad- 
stone or  Disraeli  the  verdict  would  have  been  just 
as  ludicrous.  For  such  men  come  and  go,  and  may 
serve  their  generation  well;  but  their  natural  rank 
is  negligible  compared  with  that  of  the  appointed 
few  who  create  and  who  perceive.  The  thoughts 
and  deeds  and  lives  of  mankind  will  always  be  richer, 
happier,  wiser,  saner  for  the  work  of  the  men  I  have 
named;  and  the  crowd  chose  a  politician. 

Such  an  error  I  take  to  be  of  profound  significance 
as  a  key  to  the  real  measure  of  public  enlightenment. 
It  can  neither  be  excused  nor  satisfactorily  explained ; 
and  it  should  be  regarded  as  a  verdict  of  condem- 


26  SURGERY  AND  SOCIETY 

nation  upon  our  methods  of  education,  formal  and 
informal,  upon  schools  and  colleges,  churches  and 
newspapers,  and  all  other  agencies  which  concern 
themselves  with  our  instruction  and  direction.  It 
does  not  for  a  moment  suffice  to  urge  that  in  this 
country,  unlike  France,  we  have  a  great  Imperial 
idea,  and  cannot  but  exalt  those  who  represent  and 
advocate  our  national  glory  and  military  ascendancy. 
Let  it  be  granted  that  these  are  great  and  dom- 
inant ideas.  If  that  be  so,  incomparably  the  greatest 
member  of  our  military  and  naval  state  was  Lord 
Lister,  whose  genius  has  transformed  the  conditions 
of  warfare  and  served  the  soldier  and  the  sailor  as 
they  were  never  served  before.  Surely  we  must 
exalt  not  so  much  the  man  who  makes  wars  as  the 
man  who  wins  them ;  and  though  our  surgical  standard 
in  the  Boer  war  did  not  approach  that  of  the  Japan- 
ese in  their  campaign  (which  Lord  Lister  indeed 
won  for  them),  yet  no  educated  or  quarter-educated 
nation  that  had  just  emerged  from  a  disastrous  war 
in  which  many  lives  had  been  lost,  but  many  saved 
by  the  genius  of  one  of  its  own  number,  would  ques- 
tion his  title  to  pre-eminence  over  all  its  politicians 
put  together  in  their  own  field,  to  consider  no  other. 
The  race  of  heroes  is  not  extinct;  there  will  be 
giants  in  days  to  come.  Great  pioneers  in  medicine 
and  surgery,  in  statesmanship  and  literature,  are 
safe  in  the  womb  of  Time ;  and  we  may  produce  some 
of  them.  But  if  we  are  to  deserve  them,  and  duly 
benefit  by  them,  and  avoid  the  risk  of  stoning  our 
prophets,  we  really  must  begin  to  question  ourselves 
soberly  as  a  nation  and  ask  whether,  in  our  present 


INTRODUCTION  27 

estimates  of  worth  and  honour,  we  are  not  repeating 
the  ludicrous  error  of  our  predecessors,  who  filled 
Westminster  Abbey  with  the  effigies  of  warriors  and 
politicians  for  us  to  jeer  at,  and  treated  their  greatest 
as  we  treat  ours. 

Hence  I  offer  to  the  reader's  consideration  the 
following  pages,  bearing  upon  the  work  and  value 
for  all  coming  time  of  him  "  who  saves  more  lives 
every  year  than  Napoleon  took  in  all  his  wars." 


CHAPTER  II  V 

SURGERY  AS  IT  WAS  — THE  INTRODUCTION 
OF  ANESTHESIA 

Surgery  of  some  kind  is  doubtless  almost  as  old  as 
the  human  race,  yet  its  history,  until  the  second 
quarter  of  the  nineteenth  century,  scarcely  needs 
writing.  Bold  and  skilful  operators  there  had  been 
whose  procedure  was  imitated  with  more  or  less 
success  by  their  followers.  These  men,  such  as  John 
Hunter,  contributed  substantially  to  anatomy  and 
to  surgery  as  a  craft,  but  surgery  as  a  science  was 
scarcely  developed  by  their  work.  Something  was 
learnt  regarding  the  control  of  haemorrhage.  The 
introduction  of  the  ligature,  by  which  a  cut  vessel  is; 
tied,  was  a  real  advance  on  the  almost  indescribable 
methods  which  it  superseded.  Yet  when  we  survey 
the  entire  record  of  the  past  until  the  dawn  of  our 
own  times,  and  still  more  when  we  observe  the  facts 
of  surgery  as  it  was  less  than  a  century  ago,  we  per- 
ceive that  here,  as  elsewhere,  first  principles  are  all- 
important.  Until  their  discovery  the  centuries  and 
the  millennia  may  succeed  each  other,  but  no  prog- 
ress worth  naming  is  made. 

Less  than  one  hundred  years  ago  surgery  con- 
tinued to  be  what  it  had  always  been  —  a  desperate 
remedy  for  desperate  diseases.  Two  enemies  had  to 
be  fought,  each  in  vain.     The  first  was  the  enemy  of 

28 


SURGERY  AS  IT  WAS  29 

pain,  for  which  no  efficient  drug  existed;  the  second 
was  inflammation,  the  causes  of  which  were  unknown, 
and  which  not  the  most  skilful  of  operators  could 
control  in  any  degree  at  all.  Of  these  the  latter  was 
by  far  the  more  important,  so  far  as  the  ultimate 
issue  of  the  operation  was  concerned,  and  the  key 
to  its  control  was  not  obtained  until  the  immediate 
pain  of  operation  had  been  mastered.  It  is  neces- 
sary to  say  the  immediate  pain  because  inflammation 
is  painful,  and  Listerism  has  averted  as  much  pain 
as  anaesthesia. 

Within  one-quarter  of  a  century  the  two  enemies 
of  the  surgeon,  hitherto  unbaffled,  were  conquered 
for  all  time.  We  may  name  1847  as  the  first  notable 
date  and  1868  as  the  second,  the  first  seeing  the 
introduction  of  chloroform,  and  the  second  of  car- 
bolic acid.  We  must  briefly  recall  the  birth  of  an- 
aesthesia in  order  that  we  may  see  what  surgery 
was  when  Pasteur  and  Lister  intervened,  and  also 
to  remind  ourselves  how  incalculably  the  introduc- 
tion of  anaesthesia  has  made  possible  the  full  realisa- 
tion for  mankind  of  the  value  of  their  work. 

The  details  of  the  birth  of  anaethesia  are  not  here 
our  concern.  Least  of  all  is  it  necessary  for  us  to 
enter  into  squabbles  about  priority  or  the  allocation 
of  merit.  At  any  rate,  it  seems  clear  that  Dr.  Mor- 
ton in  the  United  States  employed  ether  for  inhala- 
tion by  a  patient  undergoing  a  surgical  operation, 
and  that  very  shortly  thereafter  Sir  James  Simpson 
of  Edinburgh,  less  than  content  with  the  action  of 
ether,  made  a  number  of  observations  on  himself 
and  others  which  resulted  in  his  discovery  of  the 


30  SURGERY  AND  SOCIETY 

properties  of  chloroform,  both  for  general  surgery 
and  in  midwifery.  There  was  thus  a  period  of  some 
two  decades  during  which  surgery  was  transformed, 
so  far  as  the  immediate  features  of  operation  were 
concerned,  by  the  inhalation  of  drugs  which  totally 
abolished  all  consciousness  and  sensibility  to  pain 
until  the  surgeon's  work  was  completed.  This  was 
in  itself  a  greater  advance  than  all  previous  history 
could  record.  It  is  at  this  hour,  and  will  remain  to 
the  end  of  time,  one  of  the  most  beneficent  discov- 
eries of  the  human  mind,  but  we  must  very  clearly 
understand  that  it  did  not  create  modern  surgery 
nor  serve  in  any  degree  at  all  against  the  chief  enemy 
of  the  surgeon. 

It  is  true  that  anaesthesia  in  itself  performs  definite 
services  for  surgery  beyond  the  abolition  of  the  pa- 
tient's immediate  pain.  It  permits  the  surgeon  to 
relieve  many  patients  who  would  otherwise  not  con- 
sent to  operations  at  all ;  it  affords  him  the  great  boon 
of  complete  stillness  on  the  part  of  the  patient;  it 
achieves  the  complete  relaxation  of  muscles  which  — 
as,  for  instance,  in  dislocation  —  were  violently  con- 
tracting against  any  efforts  to  restore  the  bones  to 
their  proper  relation.  By  making  operation  painless 
it  permits  the  surgeon  to  look  very  differently  upon 
the  question  of  time;  and  though  it  has  lately  been 
shown  that,  as  might  be  expected,  the  mere  con- 
tinuance of  the  inhalation  of  anaesthetics  is  of  im- 
portance, since  these  substances  are  all  poisons,  yet 
the  surgeon  may  now  take  one,  two,  or  three  hours 
over  his  task,  if  necessary;  whereas  only  a  few  min- 
utes saw  the  end  of  human  endurance  in  days  gone 


SURGERY  AS  IT  WAS  31 

by.  Again,  anaesthesia  prevents  the  patient  from 
dying  of  immediate  shock,  as  sometimes  he  used  to 
do  when  the  first  incision  was  made,  and  we  may 
presume  that  his  powers  of  resistance,  if  inflamma- 
tion ensues,  are  less  impaired  by  a  painless  than  by 
a  painful  operation. 

But  when  all  these  factors  are  taken  into  account, 
the  most  serious  matter  of  all  remains  practically 
untouched.  It  is  difficult  to  draw  trustworthy  de- 
ductions from  such  records  as  are  available  of  the 
influence  of  anaesthesia  alone  upon  surgical  mortality, 
but  it  is  safe  to  assert  that  though  those  two  decades 
were  unlike  anything  in  the  past,  they  can  have  wit- 
nessed very  little  amelioration  or  results  in  surgery. 
The  operation  was  performed,  affording  an  utterly 
different  spectacle  and  an  utterly  different  experi- 
ence for  the  patient,  but  surgical  fever  supervened 
in  practically  every  case  as  its  custom  had  ever  been. 
Inflammation,  gangrene  and  secondary  haemorrhage 
were  liable  to  follow,  and  did  in  fact  follow  the 
work  of  the  most  skilful.  The  death-rate  was 
enormous.  The  range  of  operations  could  not  be 
materially  enlarged  because  the  great  risk  remained. 
Patients,  otherwise  unable  to  face  the  knife,  could 
give  themselves  the  chance  of  operation  when  with- 
out it  there  was  no  chance  at  all.  But  no  conscien- 
tious surgeon,  knowing  what  so  constantly  followed 
his  work,  could  operate  except  when  operation  was 
the  patient's  one  chance. 

It  is  doubtless  true  that  if,  in  some  case  taken  at 
random,  our  Listerian  precautions  were  now  omitted 
and  the  patient  were  merely  left  to  himself,  he  would 


32  SURGERY  AND  SOCIETY 

very  likely  recover  without  perhaps  much  more  than 
some  painful  inflammation  in  the  skin  where  the 
stitches  had  been  passed  through  in  closing  the 
wound.  ("But  in  the  old  days  patients  were  not  left 
to  themselves,  for  what  one  patient  had,  soon  all 
patients  had.  The  great  enemies  of  the  surgeon 
were  commonly  distributed  by  him  and  his  assistants 
with  scrupulous  fairness  amongst  all  their  patients. 
lOur  patient  left  to  himself  would  very  likely  escape 
me  inflammations  most  to  be  feared.  As  we  shall 
shortly  see,  microbes  are  not  generated  except  from 
previous  microbes,  and  previous  microbes  of  the 
same  species.  j^Each  'surgical  patient  has  to  fear 
other  patients.  His  danger  is  the  danger  of  infection 
just  precisely  as  if  he  were  a  healthy  person  lying 
in  bed  beside  a  sufferer  from  cholera  or  plague.  In 
surgery  as  it  was,  the  surgeons  and  the  nurses  were 
the  most  deadly  enemies  of  their  patients,  once  the 
deadly  microbes  made  their  appearance.  So  long  as 
no  patient  harboured  them,  all  was  well,  but  once  the 
infection  made  its  appearance  in  a  ward  its  habit 
was  to  spread  until  all  the  others  were  involved. 
Microbes  are  not  insects  and  have  no  wings;  they 
can  move  to  some  extent  in  fluids,  but  otherwise  when 
they  move  it  is  because  they  are  conveyed.  To  some 
limited  extent  they  are  conveyed  by  the  air,  but  the 
more  we  learn  the  less  importance  we  attach  to  air- 
borne infection.  Air-borne  usually  means  insect- 
borne,  as  we  now  know  for  malaria  and  yellow  fever, 
and  plague  and  sleeping-sickness.  Surgical  infec- 
tions were  conveyed  mostly  by  fingers  and  sponges, 
and  the  conditions  which  obtained  in  surgical  wards 


SURGERY  AS  IT  WAS  33 

were  similar  to  those  which  were  to  be  found  in 
Maternity  Hospitals.  The  particular  microbes  most 
to  be  dreaded  might  be  absent  and  then  all  was  well, 
but  if  once  they  made  their  appearance  in  a  single 
case,  they  were  soon  everywhere.  That  case  was 
dressed  and  then  the  infection  was  systematically 
conveyed  on  sponges  and  fingers  and  the  like  to 
every  other  patient  in  the  place.  These  conditions 
obtained  in  ordinary  surgery;  they  obtained,  it  need 
hardly  be  said,  in  the  surgery  of  war. 

We  may  briefly  describe  as  most  typical  the  dis- 
ease called  pyaemia,  which  raged  everywhere  in  the 
old  days,  but  which  has  now  become  so  uncommon 
that  the  present  writer,  though  he  spent  most  of  his 
time  for  several  years  in  a  great  hospital  containing 
hundreds  of  surgical  beds,  has  never  seen  a  case  of 
the  disease  in  his  life.  The  word  pyaemia  means  pus 
in  the  blood,  and  the  external  sign  of  the  disease  is 
the  appearance  of  abscesses  due  to  the  formation  of 
pus.  When  these  abscesses  appear  they  have  to  be 
opened,  and  it  is  this  opening  which  gives  the  oppor- 
tunity for  infection  to  be  conveyed  from  one  person 
to  another.  If  the  material  from  such  abscesses  be 
examined  under  the  microscope  it  is  found  that  it 
contains  large  numbers  of  certain  microbes  called 
cocci,  and  it  has  been  experimentally  proved  that  these 
cocci  are  the  cause  of  the  disease.  Pyaemia  is  a 
name  of  horror  to  the  medical  student  of  to-day;  it 
is  a  recollection  of  horror  to  the  doctor  whose  mem- 
ory goes  back  a  few  decades ;  it  has  caused  countless 
deaths  for  countless  ages,  but  the  nineteenth  century 
saw  the  beginning  of  its  end,  and  we  speak  of  it  and 


34  SURGERY  AND  SOCIETY 

think  of  it  now  as  we  think  of  leprosy  or  plague  in 
England,  where  once  these  diseases  flourished  and 
where  they  are  now  unknown.  But  if,  through  some 
universal  madness,  surgeons  should  decide  to  aban- 
don Listerism,  pyaemia  would  soon  be  raging  in  every 
surgical  hospital  in  the  land. 

It  is  particularly  to  be  noted  that  the  surgery  of 
the  past  was  eminently  destructive,  in  contrast  with 
the  conservative  surgery  of  to-day.  When  inflam- 
mation supervened,  as  in  a  compound  fracture,  it 
commonly  went  from  bad  to  worse.  The  essence 
of  a  compound  as  distinguished  from  a  simple  frac- 
ture is  that  it  involves  a  continuous  wound  from 
the  broken  skin  to  the  broken  bone.  In  these  cir- 
cumstances inflammation  appears  and  spreads  up- 
wards in  various  forms  and  various  routes.  For 
this  in  the  old  days  there  was  but  one  remedy,  the 
amputation  of  the  limb  in  order  to  arrest  the  up- 
ward course  of  the  inflammation.  Soon  thereafter 
symptoms  of  the  malady  would  reappear,  very  often, 
in  the  stump,  and  a  further  operation,  higher  up, 
would  be  necessary.  Evidently  it  was  the  mark  of 
this  surgery  to  be  destructive.  And,  indeed,  we  may 
say  that  the  surgeon's  business  in  those  days  was 
to  remove.  Amputation,  excision,  ablation,  always 
taking  away  was  the  surgeon's  business.  Every  day 
he  was  called  upon  to  deal  with  compound  fractures 
where  the  patient  had  to  choose  between  his  limb 
and  his  life,  with  a  very  high  chance  indeed  of  losing 
both.  For  even  when  the  broken  limb  had  been  re- 
moved, and  even  though  the  infection  had  been  ar- 
rested, there  was  still  the  surgeon's  wound  to  reckon 


SURGERY  AS  IT  WAS  35 

with,  and  the  inflammation  set  up  therein  might  very 
well  prove  fatal. 

But,  as  we  shall  abundantly  see  hereafter,  modern 
surgery  is  essentially  conservative.  It  becomes  more 
and  more  possible  to  deal  with  inflammation  wher- 
ever it  is  found  and  control  it  without  having  re- 
course to  the  removal  of  the  inflamed  part,  and  this, 
of  course,  means  everything  when,  as  in  the  case 
of  the  brain,  the  inflamed  part  is  vital.  Large  num- 
bers of  operations  are  daily  performed  where  there 
is  nothing  taken  away;  where,  indeed,  on  the  other 
hand,  there  has  been  positive  construction  achieved 
by  the  surgeon.  As  for  compound  fractures,  the 
conservatism  of  modern  surgery  expresses  itself  in 
an  immensely  diminished  use  of  the  knife  and  the 
saw,  for  it  is  often  possible,  by  the  application  of 
our  knowledge  of  the  causes  of  inflammation,  to  ar- 
rest it  at  its  site  of  origin,  thus  superseding  not  only 
the  surgery  of  the  past,  but  the  earlier  triumphs  of 
Listerism  in  the  post-operative  record  of  these  very 
cases.  For  it  will  be  evident  from  what  has  been 
said  that,  given  the  amputation  in  any  given  case, 
the  Listerian  surgeon  will  have  better  results;  but 
to-day  we  witness  the  further  triumphs  that  the  am- 
putation itself  can  often  be  averted. 

It  is  necessary  to  insist,  further,  on  the  question 
of  pain  as  it  is  witnessed  in  modern  surgery  in  com- 
parison with  the  past.  Generally  speaking,  the  skin 
is  the  most  sensitive  to  pain  of  any  tissue  or  structure, 
and,  as  we  have  seen,  the  initial  pain  of  the  surgical 
incision  is  controlled  not  by  Listerism  but  by  anaes- 
thesia.    'Acute   and  appalling  though  the  pain  of 


36  SURGERY  AND  SOCIETY! 

operation  was,  in  the  long  run  it  would  be  far  out- 
done, of  old,  by  the  patient's  subsequent  sufferings. 
Inflammation  in  greater  or  less  degree  was  th^  nor- 
mal sequel  to  operation,  and  pain  is  one  of  the  char- 
acteristics of  that  condition.  The  ancients  noted  as 
the  symptoms  of  inflammation  color y  rubor,  tumor  et 
dolor  —  heat,  redness,  swelling,  and  pain. 

Generally  such  pain  is  due  to  pressure.  A  nerve 
will  send  no  messages  until  it  be  pressed  upon,  and 
then  we  are  soon  aware  of  it.  The  pressure  of  in- 
flammation is  due  to  the  increased  quantity  of  fluid  in 
the  part  —  there,  as  we  now  know,  for  therapeutic 
purposes,  but  painful  nevertheless.  A  finger,  the 
end  of  which  is  slightly  inflamed,  may  hurt  very 
little  when  held  up  in  the  air,  but  will  begin  to  hurt 
severely  if  it  is  allowed  to  hang  down;  and  the  pain 
will  probably  be  of  a  throbbing  character,  synchro- 
nous with  the  beating  of  the  heart,  every  pulse  of 
which  raises  the  pressure  upon  the  nerves  in  the 
already  congested  part.  We  are  aware  of  the  same 
fact  in  the  throbbing  headache  that  depends  upon 
congestion  within  the  skull.  There  is  too  much  fluid 
present  within  rigidly  limited  space,  and  the  sensory 
nerves,  being  thus  pressed  upon,  cause  a  headache. 
Since  the  pain  of  inflammation  is  chiefly  due  to  pres- 
sure rather  than  to  any  chemical  effect  of  the  products 
of  inflammation  upon  the  nerve-endings,  we  can  un- 
derstand that  the  pain  will  be  much  worse  when 
the  tissue  involved  is  one  which  cannot  swell  so  as 
to  relieve  the  pressure.  Thus  it  is  that  a  very  slight 
pressure  of  intracranial  congestion,  such  as  would 
be  unnoticeable  elsewhere,  may  cause  disabling  head- 


SURGERY  AS  IT  WAS  3% 

aches ;  and  thus  it  also  is  that  toothache  is  so  painful, 
since  here  the  inflammation  is  occurring  in  a  tissue 
which  is  practically  precluded  from  swelling  at  all. 
For  the  same  reason  the  inflammatory  processes  that 
occur  in  bone  are  peculiarly  painful,  as  only  too  many 
victims  of  accident  knew  in  the  bad  old  days. 

Thus  pre-Listerian  surgery  was  most  eminently 
painful  surgery,  for  inflammation  was  its  normal 
sequel,  and  though  anaesthesia  was  a  mighty  boon, 
the  worst  was  always  yet  to  come.  Beneficent  though 
he  might  be,  the  surgeon  was  always  the  inflicter 
of  pain,  since  time  began  until  the  seventies  of  last 
century.  (Nowadays,  as  we  shall  see,  the  surgeon 
is  above  all  the  enemy  of  inflammation,  which  is  to 
say  that  he  is  the  enemy  of  pain.  His  own  pro- 
cedures involve  no  pain,  since  the  knife  and  the 
needle  are  used  under  anaesthesia,  and  no  inflamma- 
tion follows  their  use;  and  all  manner  of  inflamma- 
tions causing  pain  are  successfully  arrested  by  the 
surgeon's  procedure.  The  surgeon's  knife  to-day 
inflicts  no  pain;  it  alleviates  and  prevents  far  more 
pain  than  the  physician's  drugs.  I 

But  if  we  are  to  understancfthe  accomplishment 
of  Listerism  we  shall  find  it  necessary  briefly  to  re- 
view our  modern  knowledge  of  a  certain  most  im- 
portant group  of  living  things,  wholly  unknown  until 
the  nineteenth  century,  without  which  the  higher 
forms  of  life,  including  ourselves,  could  not  exist, 
and  yet  which  number  amongst  them  our  greatest 
foes  and  furnish  the  key  to  the  control  of  nearly  all 
forms  of  disease  —  most  notably  surgical  inflamma- 
tion. To  these  microbes,  then,  the  following  chap- 
ter must  be  devoted. 


CHAPTER  III 

MICROBES 

The  name  of  microbes  was  given  by  Pasteur  to 
the  lowest  of  all  living  things,  known  to  botanists  — 
for  they  are  plants  —  as  the  Schizomycetes  or  Fis- 
sion-fungi. The  name  is  an  allusion  to  their  method 
of  reproduction,  which  is  by  simple  fission  or  split- 
ting. The  vital  significance  of  microbes  depends, 
however,  not  upon  the  fact  that  they  divide  by  fis- 
sion, but  that  they  are  fungi.  The  essential  char- 
acter of  a  fungus  is  that  it  is  a  plant  which  does  not 
contain  chlorophyll.  It  is  worth  while  to  observe 
what  this  means,  since  it  is  the  key  to  the  mode  of 
life  of  the  fungi  and  to  all  that  follows  therefrom. 

All  plants  whatever,  the  fungi  excepted,  contain 
either  the  green  colouring  matter  called  chlorophyll, 
or  one  of  its  modifications  such  as  are  found  in  ma- 
rine plants.  In  virtue  of  their  chlorophyll,  plants 
are  enabled,  under  the  influence  of  sunlight,  to  feed 
upon  the  carbonic  acid  of  the  air  or  of  water.  The 
presence  of  chlorophyll  means,  therefore,  that  a  plant 
can  live  on  inorganic  food.  Given  air,  light,  water, 
and  certain  salts  it  is  satisfied.  In  any  theories  we 
may  entertain  as  to  the  first  forms  of  life,  we  are 
bound  to  assume  that  these  first  forms  possessed  the 
essential  characters  of  the  green  plant  as  we  know 

38 


MICROBES  '     39 

it.  They  must  have  been  able  to  feed  upon  inor- 
ganic food,  since  there  was  none  other  for  them. 

It  follows  that  the  fungi  cannot  be  regarded  as 
representatives  of  the  earliest  forms  of  life.  They 
must  have  lost  their  chlorophyll  or  whatever  dis- 
charged the  function  of  chlorophyll  in  primitive 
times.  They  no  longer  possess  the  characteristic 
plant  faculty  of  finding  nourishment  in  the  inor- 
ganic world.  They  are,  therefore,  compelled,  like 
animals,  to  live  upon  materials  which  have  been  con- 
structed by  previous  life.  Upon  that  fact  depends 
all  that  follows  for  us  from  the  existence  of  the 
fungi.  Here  we  may  ignore  the  higher  fungi,  such 
as  the  mushrooms,  and  concern  ourselves  entirely 
with  the  microbes  —  far  and  away  the  most  impor- 
tant of  the  fungi,  the  most  useful  and  the  most 
deadly,  the  most  numerous,  the  most  minute  and  the 
most  recently  known. 

By  far  the  greater  number  of  microbes  feed  upon 
the  organic  matter  of  dead  bodies  from  which  the 
life  has  departed,  or  upon  waste  products  —  which 
cannot  be  said  to  have  ever  been  alive  —  of  living 
things.  All  microbes  which  have  this  mode  of  life 
are  called  saprophytes.  They  are,  indeed,  humble; 
they  are  doubtless  to  be  classed  as  degenerate,  but 
they  fulfil  a  most  important  function  in  the  world 
of  life.  Without  them  the  surface  of  the  earth 
would  long  ago  have  become  a  charnel  house.  Upon 
these  microbes  the  existence  of  all  the  higher  forms 
of  life  depends.  Their  function  is  to  break  up  and 
destroy  the  dead  bodies  and  the  products  of  all  other 
living  things,   restoring  their  chemical  constituents 


4o  SURGERY  AND  SOCIETY 

to  earth  and  air,  whence  they  were  originally  wrested 
by  the  green  plant;  and  whence,  again  and  again, 
new  green  plants  will  wrest  them.  Without  these 
saprophytes  the  cycle  of  life  could  not  be  maintained, 
and  we  who  discuss  them  could  never  have  been 
evolved.  Microbes  are  the  great  purifiers,  the  great 
scavengers,  the  great  restorers  of  the  world,  and 
this  they  are  because  of  that  peculiar  and,  in  a  sense, 
degenerate  mode  of  life  which  depends  upon  their 
loss  of  chlorophyll. 

But  certain  forms  of  microbes  have  stepped  across 
the  line  which  divides  the  dead  from  the  living. 
Their  natural  function,  as  we  may  say,  is  to  disin- 
tegrate the  bodies  of  the  dead.  They  have,  however, 
learnt,  as  we  may  suppose,  in  the  course  of  the  ages, 
to  attack  the  bodies  of  the  dying,  and  finally,  in 
some  instances,  to  invade  and  thrive  in  the  bodies 
of  the  previously  healthy.  The  saprophyte  or  liver 
upon  the  dead  has  now  become  a  parasite  or  liver 
upon  the  living.  Of  the  total  number  of  microbes 
only  very  few  are  parasitic,  say  less  than  three  score 
all  told,  but  they  suffice  to  produce  between  them 
very  nearly  all  the  ills  that  flesh  is  heir  to. 

An  important  complexity  is  furnished  by  the  fact 
that  one  and  the  same  species  of  microbe  may  at 
one  time  live  upon  a  living  body,  and  at  another 
time  in  some  organic  medium  which,  though  the 
product  of  life,  is  not  itself  alive.  Thus  most  of 
the  microbes  of  disease  can  be  cultivated  in  test- 
tubes  containing  beef  jelly  or  milk.  At  such  times 
they  are  of  course  mere  saprophytes,  but  saprophytes 
with  the  faculty  of  becoming  parasites.     This  adapt- 


MICROBES  41 

ability  is  of  high  importance  to  us  because,  if  a 
microbe  cannot  live  outside  the  human  body,  the 
conditions  of  infection  will  be  very  different  from 
those  which  obtain  in  the  case  of  a  microbe  like  the 
typhoid  bacillus,  for  instance,  which  can  spend  a 
whole  winter  in  the  soil  between  leaving  one  host 
and  infecting  another.  The  microbe  which  has  not 
the  power  of  leading  a  saprophytic  existence  must  be 
conveyed  immediately  from  one  host  to  another  if  it 
is  to  survive;  unless,  indeed,  we  are  to  reckon  with 
the  "  vie  suspendue  "  or  "  vie  ralentie  " —  illus- 
trated by  century-old  seeds  which  can  still  germinate. 
The  term  microbe  is  commonly  restricted,  though 
without  etymological  necessity,  to  the  humble  vege- 
table forms  which  we  have  been  hitherto  consider- 
ing. But  there  is  no  particular  reason  why  the 
term  should  not  be  extended  to  include  other  minute 
forms  of  life  which  are  not  vegetable.  Such  an  ex- 
tension would  be  convenient  because  it  has  been 
found  in  recent  years  that  there  are  various  minute 
animal  cells  which  are  capable  of  leading  a  parasitic 
existence  after  the  fashion  of  certain  microbes,  and 
which  give  rise  to  disease  in  a  similar  fashion. 
Malaria,  for  instance,  which  causes  more  illness, 
though  tuberculosis  causes  more  deaths,  than  any 
other  disease  whatsoever,  is  due  to  the  invasion  of 
the  body  by  a  minute  organism  which  is  not  vegeta- 
ble but  animal.  Syphilis,  again,  which  is  one  of  the 
most  important  of  all  diseases,  has  lately  been  shown 
to  be  due  to  an  animal  parasite,  and  the  same  is  true 
of  sleeping-sickness.  The  surgeon,  however,  is 
much  more  nearly  concerned,  as  a  rule  with  the  vege- 


42  SURGERY  AND  SOCIETY 

table  microbes  which  were  earlier  discovered  and 
which  cause  most  of  the  conditions  against  which  he 
fights. 

Parasitism  is  one  of  the  universal  facts  of  the 
living  world.  Swift's  lines  about  fleas  and  lesser 
fleas  "  and  so  ad  infinitum  "  are  nearly  true.  We 
observe  the  characters  of  some  minute  worm,  and 
we  find  its  blood  constantly  inhabited  by  parasites 
not  by  any  means  dissimilar  from  some  of  those 
which  are  apt  to  infest  the  blood  of  man.  Though 
life  be  manifested  in  individuals,  the  whole  of  the 
living  world  may  almost  be  looked  upon  as  a  single 
organism  which  is  but  partly  discontinuous.  Every 
species  that  is  evolved  furnishes  an  environment, 
a  home,  a  host,  and  a  feast,  for  some  other  species. 
Thus  evolution  takes  a  curious  course.  The  pro- 
duction of  the  higher  apes  made  possible  the  pro- 
duction of  humble  parasitic  species  which  could  live 
in  their  tissues  but  in  those  of  no  earlier  animals. 
In  similar  fashion,  though  man  is  the  highest  prod- 
uct of  evolution,  he  is  not  the  latest  —  a  point 
worthy  of  remembrance  by  those  who  suppose  that 
evolution  is  synonymous  with  progress.  The  latest 
products  of  evolution  are  various  microbic  species 
which  can  live  nowhere  but  in  the  tissues  of  man. 
It  is  plain  that  they  must  be  of  later  origin  than 
he  is.  At  the  same  time,  it  is  worth  noting  that 
observations  made  upon  the  anthropoid  apes  reveal 
our  blood  relationship  with  those  species  in  a  new 
and  striking  fashion,  by  showing  that  almost  all,  if 
not  all,  of  the  parasitic  maladies  formerly  thought 
peculiar    to   man    can   be    communicated    to    apes, 


MICROBES  43 

though  not  to  the  lower  monkeys  nor  to  any  other 
species. 

If  we  survey  parasitism  as  a  whole,  realise  it  to 
be  a  general  fact  of  the  living  world,  we  shall  ex- 
pect it  to  obey  the  ordinary  laws  which  govern  the 
relations  of  species.  Each  species  for  itself  is  a 
law  of  life.  Darwin  long  ago  showed  that  it  was 
impossible  to  find  any  instance  where  a  species  dis- 
played any  character  for  the  sake  of  another  species. 
Within  the  specific  limit  individuals  live  largely  for 
each  other,  but  physiological  altruism  never  tran- 
scends this  limit.  It  is  true  that  species  enter  into 
mutual  relations  —  in  which  each  is  concerned,  how- 
ever, wholly  for  its  own  advantage.  The  best  in- 
stance of  such  symbiosis,  as  it  is  called,  is  the  lichen, 
which  is  constituted  by  an  alga  and  a  fungus,  each 
living  for  itself,  but  each  taking  an  advantage  from 
the  other.  Vastly  more  common  than  symbiosis, 
however,  which  is  only  exceptional,  is  parasitism, 
and  if  we  remember  that,  according  to  the  principles 
already  laid  down,  the  parasite  is  seeking  only  its 
own  advantage,  we  shall  be  prepared  to  observe  evil 
consequences  to  the  host  in  not  a  few  cases.  These 
evil  consequences  constitute  the  greater  part  of  what 
we  call  disease,  whether  we  find  it  in  man  or  in  the 
lower  animals  or  in  the  vegetable  world. 

Not  all  parasitism,  however,  involves  the  disease 
of  the  host.  It  is  indeed  to  the  best  interest  of  the 
parasite  that  the  host  shall  not  be  killed,  for  if  that 
occurs  the  parasite  usually  succumbs  also.  It  is 
probably  true  that  all  living  species,  except  the  most 
minute,  are  the  hosts  of  parasites  which  do  them 


44  SURGERY  AND  SOCIETY 

no  appreciable  harm.  These  parasites  are  found 
upon  the  surface  of  the  body  and  within  its  tissues. 
One  species  of  bacilli  has  been  found  in  the  bowel 
of  a  baby  as  early  as  eleven  days  after  birth,  and 
is  to  be  found  in  every  human  bowel  throughout 
life.  There  appear  to  be  some  thirty  kinds  of  mi- 
crobes which  must  be  reckoned  as  more  or  less  normal 
inhabitants  of  the  human  mouth  alone.  No  cleanli- 
ness, whether  internal  or  external,  will  entirely 
purge  us  of  these  guests.  But  it  is  only  under  certain 
conditions  that  this  universal  fact  of  parasitism  be- 
comes of  urgent  moment  to  the  host.  Perhaps  there 
gains  admission  to  his  body  a  form  of  parasite  with 
which  no  vital  equilibrium  can  be  established  and 
which  multiplies  to  such  an  extent  that  his  life  is 
destroyed,  or  is  perhaps  saved  after  a  battle  which 
he  calls,  it  may  be,  an  attack  of  pneumonia  or  typhoid 
fever.  In  other  cases,  a  condition  of  equilibrium 
perhaps  long  existing  is  disturbed.  The  parasite 
which  has  been  harboured  in  moderate  numbers, 
presumably,  for  any  length  of  time,  begins  for  some 
reason  or  other  to  multiply,  and  consequences  may 
follow  similar  to  those  which  followed  the  introduc- 
tion of  an  entirely  new  parasite.  The  microbe  of 
pneumonia,  for  instance,  appears  to  be  a  practically 
normal  inhabitant  of  many  mouths  and  throats,  es- 
pecially of  those  who  attend  cases  of  the  disease. 
But  it  is  only  when  some  unknown  factor  is  disturbed 
in  the  vital  economy  of  the  person  who  harbours 
the  microbe  that  he  in  his  turn  is  really  infected  by 
the  disease.  Such  facts  as  these  suggest  to  us  the 
existence  of  those  problems  of  immunity  and  sus- 


MICROBES  45 

ceptibility  and  their  possible  control  by  man  which 
have  recently  begun  to  play  a  most  important  part 
in  surgery.  Thus,  to  take  an  instance,  a  person 
who  suffers  from  the  formation  of  little  swellings  in 
the  eyelids  may  be  relieved  either  by  surgery  in  the 
ordinary  sense  of  the  word,  that  is,  by  the  perform- 
ance of  a  Listerian  operation  —  which  may,  how- 
ever, have  to  be  repeated  indefinitely;  or,  on  the 
other  hand,  the  tendency  to  the  production  of  these 
swellings  may  be  entirely  arrested  by  the  introduc- 
tion into  his  blood  of  a  substance  called  anti-staphyl- 
ococcus  serum,  or  when  some  only  too  well-known 
ally,  such  as  alcohol  is  freely  introduced  which  is 
derived  from  the  coccus  or  microbe  that  causes  the 
swellings,  and  so  modifies  the  patient's  body  that 
this  particular  coccus,  though  it  may  still  visit  his 
eye,  can  do  no  harm  there.  Such  a  procedure  may 
be  called  medical,  perhaps,  rather  than  surgical,  but 
it  is  the  treatment  of  what  is  ordinarily  called  a 
surgical  disease,  and  it  depends  upon  principles  which 
were  largely  elucidated  by  the  greatest  surgeon  of  all 
time.     To  this  subject  we  shall  perforce  return. 

The  foregoing,  considered  as  a  whole,  throws  an 
unexpected  light  upon  a  proposition  which  contains 
a  measure  of  truth  and  is  frequently  exploited  by 
cranks  even  at  the  present  day.  It  is  that  man  alone 
is  subject  to  disease  and  that  this  is  the  fruit  of  his 
misconduct.  If,  therefore,  he  will  only  lead  the 
11  simple  life,"  or  avoid  certain  errors,  such  as,  shall 
we  say,  the  cooking  of  his  food  or  the  eating  of 
flesh,  he  will  find  himself  as  free  from  disease  as  his 
humbler  but  wiser  relatives. 


46  SURGERY  AND  SOCIETY 

Now  it  is  impossible  to  question  that  men's  habits 
do  often  subject  them  to  disease  which  the  lower 
animals  avoid.  The  modern  surgeon  knows,  for  in- 
stance, that,  as  we  shall  see  in  a  later  chapter,  alco- 
hol lowers  the  resistance  to  infection,  and  so  in- 
creases the  risk  that  his  patient  may  suffer  from 
inflammation.  But  though  there  are  many  instances 
such  as  this,  it  will  be  seen  that  disease  due  to  para- 
sitism is  really  a  general  factor  of  the  life  of  the 
world,  and  can  no  longer  be  laid  entirely  at  the  door 
of  man's  imprudence  or  folly.  The  lower  animals 
suffer  very  largely  as  we  do;  they  have  their  own 
specific  diseases  as  we  have  ours;  and  often  we  find, 
as  in  the  case  of  glanders,  that  the  disease  of  the 
horse  may  very  easily  become  the  disease  of  the 
ostler.  As  for  the  ordinary  cocci  of  surgical  in- 
flammation, they  are  very  adaptable  and  will  thrive 
in  the  wounds  of  many  of  the  lower  animals  as  read- 
ily as  in  those  of  man.  The  propositions  of  our 
faddist  reformers  must  therefore  be  accepted  with 
caution.  Most  human  maladies  are  consequences  of 
the  general  factors  of  parasitism,  which  produces 
precisely  similar  consequences  in  other  species.  A 
man's  habits  in  regard  to  cleanliness  and  eating  and 
drinking  are  important  in  many  connexions,  not  least 
of  all  in  connexion  with  disease;  but  it  is  impossible 
to  declare  that  they  are  all-important  or  indeed  any- 
thing like  as  important  as  many  ardent  advocates  of 
personal  hygiene  are  apt  to  assert.  In  the  matter 
of  malaria,  for  instance,  the  secret  of  health  is  not 
to  be  bitten  by  the  mosquito  which  conveys  the  para- 
site.    In  the  matter  of  plague  the  secret  of  health 


MICROBES  47 

is  to  be  found  in  no  semi-ritual  observance  but  sim- 
ply in  not  being  bitten  by  a  flea  which  has  previously 
bitten  and  been  infected  by  a  rat  suffering  from  the 
disease.  Instances  might  be  multiplied  indefinitely, 
and  the  lessons  taught  us  are  very  clear  and  precise. 
The  problem  of  disease  must  be  looked  upon  as 
primarily  a  biological  one.  The  greater  part  of 
disease  is  a  problem  in  the  relations  between  living 
species.  Man  and  the  lower  animals  are  equally 
involved  in  these  questions.  It  is  not  primarily  a 
question  of  right-doing  or  wrong-doing  except  in  so 
far  as  it  is  a  question  of  right-doing  and  wrong-doing 
at  the  present  day  to  acquaint  ourselves  with  the 
laws  of  disease  and  to  act  accordingly.  Where  the 
bacillus  of  plague  exists,  together  with  the  black 
rat  which  is  susceptible  to  that  disease,  and  which 
has  fortunately  been  driven  out  of  our  land  by  the 
susceptible  but  non-domestic  brown  rat,  there  plague 
will  occur  quite  independently  of  morality  or  of 
Providence.  The  plague  bacillus  has  to  live  its  life, 
and  its  first  business  is  to  find  food;  as  is  the  first  busi- 
ness of  man.  The  rat  flea,  also,  has  to  live  its  life, 
and  its  first  business  also  is  to  find  food.  Man  is 
simply  one  of  the  species  concerned. 

In  the  foregoing  case  and  in  many  others  man 
derives  the  infection  from  one  of  the  lower  animals, 
but  the  infection  may  just  as  easily  go  the  other 
way.  It  has  been  seen  that  the  anthropoid  apes 
are  subject  to  many  forms  of  human  disease  in  con- 
sequence of  their  close  affinity  with  mankind.  That 
explains  why  a  glass  screen  is  interposed  at  the 
Zoological  Gardens  in  London  between  the  visitors 


48  SURGERY  AND  SOCIETY 

and  the  anthropoid  apes,  though  none  such  is  neces- 
sary in  the  ordinary  monkey-house.  We  have  found 
that  the  death-rate  amongst  the  apes  from  tubercu- 
losis and  influenza  has  been  greatly  diminished  since 
the  interposition  of  this  screen  has  protected  them 
from  infection  by  the  visitors. 

The  moral  of  this  chapter  will  now  be  clear.  It 
is  that  the  moralist  must  be  cautious  in  his  pro- 
nouncements upon  the  subject  of  disease.  When  he 
finds  that  the  chief  of  human  diseases,  tuberculosis, 
is  also  found  not  merely  in  apes  and  monkeys  but  in 
four-footed  beasts  and  fish  and  fowl;  when  he  finds, 
also,  that  wounds  in  almost  any  of  these  creatures 
are  liable  to  disastrous  invasion  by  one  and  the  same 
kind  of  microbe,  he  will  more  and  more  come  to  re- 
gard disease  as  a  natural  phenomenon  due  to  natural 
causes,  and  none  other,  indeed,  than  in  the  majority 
of  cases  a  manifestation  of  the  struggle  for  exist- 
ence as  that  struggle  occurs  between  different  living 
species.  The  investigation  of  these  subjects  is  not 
impious,  even  though  it  takes  little  concern  of  Provi- 
dence, even  though  it  tends  more  and  more  to  assimi- 
late man  and  his  conditions  to  the  rest  of  the  living 
world.  Further,  the  elucidation  of  the  causes  of 
disease  benefits  not  only  man,  but  also  all  those 
forms  of  life  which  he  takes  under  his  care.  Pas- 
teur and  Lister  are  the  friends  of  the  dog  and  the 
horse,  no  less  than  the  friends  of  man.  There  is 
much  for  the  moralist  to  inculcate,  even  though  we 
qualify  in  some  degree  the  enthusiastic  assertion  that 
regular  and  simple  modes  of  life  will  protect  from 


MICROBES  49 

all  disease.  It  remains  to  be  taught  that  it  is  part 
of  true  morality  fearlessly  to  investigate  these  mat- 
ters and  to  act  upon  the  knowledge  thus  obtained. 

Finally,  it  is  important  for  us  clearly  to  realise  the 
definiteness  of  microbic  life  and  its  obedience  to  the 
laws  which  are  exemplified  in  all  higher  forms  of 
life.  In  the  first  place,  microbes  are  the  descendants 
of  previous  microbes  just  as  certainly  as  human  be- 
ings are  the  descendants  of  previous  human  beings. 
They  are  no  more  generated  out  of  any  kind  of 
material  than  we  are.  If  microbes  are  found  in  any 
part  of  the  human  body  —  as,  for  instance,  in  a 
wound  made  by  a  bullet  or  a  surgeon  —  they  have 
certainly  been  conveyed  there.  They  are  neither 
generated  spontaneously  from  dead  matter,  so  far 
as  we  know,  nor  are  they  derived  from  the  tissues 
of  any  living  creature  in  whom  they  may  be  found. 
The  whole  theory  and  practice  of  surgery  and  pre- 
ventive medicine  would  be  different  if  the  facts  were 
otherwise.  I  am  by  no  means  here  prepared  to  as- 
sert that  which  is  called  spontaneous  generation  of 
life  does  not  occur,  but  it  certainly  does  not  occur 
so  far  as  the  surgeon  and  the  hygienist  are  con- 
cerned. The  objects  of  their  attention  are  members 
of  definite  living  races,  obeying  the  general  law 
omnis  cellula  e  celluld  —  every  cell  from  a  cell.  If 
the  surgeon  finds  such  and  such  an  organism  in  a 
wound  made  by  him,  he  knows  that  he  or  his  assist- 
ants put  it  there.  It  did  not  "  happen  there  " ;  it 
was  not  generated  from  the  patient's  tissues  nor 
from  the  exudation  into  the  wound.     It  has  as  defi- 


50  SURGERY  AND  SOCIETY 

nitely  to  be  accounted  for  there  as  if  he  had  found 
a  butterfly  or  a  halfpenny  in  its  place. 

Further,  these  races,  though  subject  to  variation 
and  modification,  like  other  living  races,  are  never- 
theless definite  and  distinct.  It  is  not  microbes  in 
general  that  the  surgeon  has  to  fear.  It  is  true  that 
microbes  are  to  be  found  everywhere;  they  are  to 
some  extent  in  the  air;  they  are  to  be  found  on 
every  surface.  Lister  asked  the  surgeon  to  act  as 
if  everything  around  him  were  covered  with  green 
paint  and  must  be  avoided.  Everything  is  indeed 
covered  with  microbes,  and  should  therefore  on 
general  principles  be  avoided.  But  the  microbes 
which  we  have  to  fear  are  by  no  means  ubiquitous, 
and  wherever  we  find  them  they  are  derived  from 
previous  microbes  of  the  same  species.  The  laws  of 
heredity  obtain  here  as  elsewhere.  If  a  virulent 
inflammation  develops  in  a  surgeon's  patient,  and 
is  shown  to  be  due  to  a  definite  microbe,  and  if  he 
has  lately  been  attending  another  patient  in  whom 
that  same  species  of  microbe  is  multiplying,  the 
chances  are  quite  as  high  as  need  be  that  he  carried 
it,  perhaps  under  his  finger  nails  or  in  his  beard, 
from  one  patient  to  the  other.  We  are  dealing  with 
things  so  minute  that  the  naked  eye  cannot  see  them, 
but  they  are  just  as  real,  and  the  laws  of  their  multi- 
plication and  dissemination  just  as  definite,  as  if  they 
were  African  elephants.  It  is  a  first  principle  in 
modern  surgery  and  hygiene  that  all  microbes  have 
to  be  accounted  for,  and  they  have  to  be  accounted 
for  just  as  if  they  were  individuals  of  higher  races. 

The  foregoing  summarises  as  fairly  as  may  be  our 


MICROBES  51 

present  knowledge  of  this  subject  —  knowledge  most 
of  it  familiar  to  all  of  us.  In  the  next  chapter  we 
shall  learn  something  incidentally  of  the  history  of 
its  attainment. 


CHAPTER  IV 

PASTEUR  THE  FORERUNNER 

No  great  man  stands  alone.  Necessary  though  he 
be,  unique,  solitary,  and  indispensable,  he  is  yet  a 
social  product,  a  son  of  Man,  and  in  his  voice  the 
immortal  dead  yet  speak.  The  affiliation  is  some- 
times definite,  sometimes  obscure.  We  know  that 
the  genius  of  Bach  is  to  be  heard  no  less  in  Delius 
than  in  Beethoven;  and  that  Galileo  and  Kepler 
served  for  Newton  to  raise  his  eyes  upon.  In  other 
cases  a  genius  appears  to  arise  by  spontaneous  gen- 
eration ;  as  we  used  to  fancy,  until  the  other  day,  of 
the  great  Athenian  age.  But  even  there,  as  we  now 
know,  we  are  witnessing  not  a  beginning  but  an 
efflorescence,  of  which  the  root  and  stalk  are  slowly 
being  disclosed  by  modern  archaeology. 

In  the  case  of  modern  surgery,  the  immediate 
creation  of  Lord  Lister,  all  men  should  know  that 
the  forerunner  was  Louis  Pasteur,  the  greatest  ben- 
efactor of  mankind  in  recorded  time:  to  whom  not 
only  modern  surgery  owes  its  prime  genesis,  but  also 
preventive  medicine  —  and  such  curative  medicine 
as  may  still  be  necessary  in  the  future. 

In  the  last  chapter  we  surveyed,  in  general  out- 
line, our  modern  knowledge  of  microbes  —  or  micro- 
organisms, in  the  quite  unnecessary  modern  version 
of  Pasteur's  term.     We  must  now  trace,  with  equal 

52 


PASTEUR  THE  FORERUNNER  53 

brevity,  the  main  steps  by  which  the  revelation  was 
obtained,  and  its  application  to  the  chief  needs  of 
man  effected. 

The  cell-theory  of  the  structure  of  living  things 
was  the  first  achievement.  Schleiden  and  Schwann 
showed,  first  in  plants,  and  then  in  animals,  that  the 
body  of  a  living  being  is  made  up  of  cells.  It  did 
not  take  long  for  the  microscopist  to  discover  that 
yeast  is  a  living  thing,  made  up,  like  all  others,  of 
living  cells.  Yeast  is  indeed  a  unicellular  vegetable 
organism;  and  though  of  higher  organisations  than 
the  bacteria,  it  is  also  a  fungus.  It  is  not  one  of 
the  fission-fungi,  however,  but  effects  its  reproduc- 
tion by  a  process  of  budding  or  gemmation,  the  buds 
becoming  detached  from  the  mother  cell  and  living 
independent  lives  without  her  actual  disappearance, 
as  in  the  case  of  the  microbe  that  splits  into  two. 
Nor  is  yeast  directly  a  cause  of  any  disease  of  ours, 
though  in  some  cases  of  dyspepsia,  when  the  stom- 
ach fails  to  produce  in  adequate  degree  the  hydro- 
chloric acid  which  is  at  once  a  digestive  agent  and  a 
powerful  antiseptic  wherein  few  fungi  can  live,  the 
yeast  plant  may  be  found  in  the  gastric  contents. 
Indirectly,  of  course,  the  yeast  plant  is  of  high  im- 
portance in  pathology,  as  its  particular  toxin,  ethyl- 
alcohol,  which  it  produces  by  the  fermentation  of 
sugar,  is  a  leading  cause  of  tissue-degradation  and 
disease. 

But  it  is  just  because  the  yeast  plant  effects  a 
fermentation  that  it  is  of  such  interest  to  us  and  our 
present  narrative.  Fermentation,  from  whatever 
point  of  view  it  be  considered,  is  one  of  the  most 


54  SURGERY  AND  SOCIETY 

important  words  in  the  dictionary,  and  whatever 
throws  light  upon  it  illuminates  the  central  problem 
of  biology,  which  is  the  nature  of  life.  That  we 
now  realise,  but  the  first  step  towards  our  modern 
point  of  view  was  taken  when  it  was  found  that  a 
living  cell  causes  fermentation.  The  accepted  view 
was  that  fermentation  is  caused  by  some  chemical 
agent,  not  alive,  which  is  called  a  ferment,  and  which 
effects  chemical  changes  of  certain  kinds  without  it- 
self being  changed  or  consumed.  That  view  is  also 
the  present  view,  but  with  a  notable  difference.  For 
the  discovery  of  the  life  of  the  yeast  plant  plainly 
led  to  the  view  that  fermentation  is  a  vital  phenome- 
non, as  distinguished  from  a  chemical  one. 

We  now  know  that  fermentation  may  be  both  a 
vital  and  a  chemical  phenomenon.  We  have  lately 
done  what  Liebig  and  Pasteur  and  the  great  dis- 
putants of  those  days  could  not  do,  and  have  been 
able  to  extract;  from  within  the  body  of  the  yeast 
plant  the  ferment,  or  series  of  ferments,  by  which 
it  does  its  work.  Those  ferments  are  not  themselves 
alive,  and  will  effect  their  characteristic  results  in 
the  absence  of  all  life;  and  thus  the  chemical  theory 
of  fermentation,  upheld  most  notably  by  the  illus- 
trious Liebig,  is  justified.  But  evidently  it  remains 
of  no  less  importance  that  these  ferments  are  pro- 
duced in  the  body  and  by  the  life  of  a  living  thing. 

Though  fermentation  can  be  effected  apart  from 
life,  whether  by  ferments  made  by  living  things,  or 
by  other  agents  such  as  platinum  in  a  certain  state 
of  subdivision,  and  though  the  study  of  fermentation 
apart  from  life  has  the   extraordinary  importance 


PASTEUR  THE  FORERUNNER  55 

that  it  promises  to  elucidate  the  nature  of  life  itself, 
which  may  depend  upon  a  sequence  of  fermentations, 
yet  for  our  purposes  it  suffices  simply  to  accept  the 
notable  fact  that  yeast,  the  fermenter  of  sugar,  is  a 
minute  living  plant.  From  that  discovery  we  can 
proceed  far. 

The  fermentation  of  sugar  by  the  yeast  plant  is  of 
practical  importance  because  the  production  of  alco- 
holic liquors  depends  upon  it.  The  wine  and  brew- 
ing industries  merely  apply  the  science  of  fermenta- 
tion; and  if  one  wine  or  beer  differs  from  another, 
it  is  a  difference  of  fermentation  that  will  be  found. 
Further,  the  fermentation  requires  to  be  directed 
and  controlled;  and,  as  was  soon  found,  not  yeast 
alone  is  concerned  with  the  making  of  such  com- 
plex products  as  wine  or  beer.  To  take  only  one 
case,  the  alcohol  produced  by  yeast  is  itself  subject 
to  fermentation,  and  may  be  converted  into  acetic 
acid,  this  being  the  essential  change  by  which  wine 
becomes  vinegar.  This  change,  as  we  now  know,  is 
effected  by  a  microbe,  known  as  the  bacillus  aceticus, 
which  is  unique  among  living  things  in  that  it  feeds 
upon  alcohol  —  by  its  destruction,  however  —  nor- 
mally and  profitably,  that  being  its  appointed  diet. 

iWe  may  now  turn  towards  the  figure  of  the  young 
Pasteur,  who  was  destined,  beyond  all  other  men, 
to  throw  light  upon  this  subject  and,  by  championing 
the  vital  theory  of  fermentation  (though  that,  as  we 
have  seen,  is  not  really  opposed  to  the  chemical 
theory),  to  found  the  modern  sciences  of  pathology, 
medicine,  surgery,  and  hygiene. 

This  greatest  doctor  of  all  time  never  passed  an 


56  SURGERY  AND  SOCIETY 

examination  in  medicine,  but  was  destined  to  be  a 
chemist.  From  the  very  first  he  distinguished  him- 
self in  chemical  research,  and  turned  from  the  ac- 
customed paths  towards  the  undiscovered  land  which 
he  was  to  chart,  only  against  the  wishes  and  warn- 
ings of  his  distinguished  teachers,  Dumas  and  Biot, 
who  feared  that  the  promising  boy  might  lose  his 
way. 

But  his  first  piece  of  independent  research  fore- 
shadowed the  direction  in  which  he  was  thereafter 
to  go,  and  is  well  worth  recalling  here  for  its  own 
interest  and  for  its  bearing  upon  our  subject. 
Briefly,  the  facts  which  the  young  chemist  served  to 
elucidate  are  these.  Ordinary  tartaric  acid  has  no 
influence  upon  a  ray  of  light'  passed  through  it, 
though  that  ray  has  previously  been  "  polarised," 
so  that  all  its  vibrations  are  in  one  direction  only 
and  will  reveal  any  influence  upon  that  direction. 
But  ther$  are  other  forms  of  tartaric  acid  which  are 
"  optically  active,"  as  chemists  say,  in  that  one  of 
them  is  u  dextro-rotatory,"  rotating  a  ray  of  polar- 
ised light  to  the  right,  whereas  the  other  is  "  laevo- 
rotatory,"  rotating  the  ray  to  the  left.  Now  the 
optically  inert  acid  really  consists  of  a  mixture  of 
the  two  active  acids  in  such  a  proportion  that  they 
exactly  neutralise  each  other's  action,  and  permit  the 
ray  of  polarised  light  to  emerge  from  a  solution  of 
them  in  the  same  plane  as  that  in  which  it  entered. 
Under  certain  conditions  the  inert  acid  can  be  made 
active,  because  one  of  the  constituents  is  destroyed 
by  the  growth  of  a  bacillus,  and  the  other,  which  the 
bacillus  does  not  touch,  is  left  behind,  and  exerts  its 


PASTEUR  THE  FORERUNNER  57 

optical  properties  unantagonised.  This  remarkable 
discovery  of  Pasteur's  leads  us  to  realise  that  the 
molecule  of  tartaric  acid  may  exist  in  two  forms, 
exactly  identical  save  that  one  is,  so  to  say,  the  mir- 
ror image  of  the  other;  differing,  in  other  words,  as 
a  right  hand  does  from  a  left;  and  this  fact  enables 
us  to  found  and  prosecute  a  "  chemistry  in  space  " 
or  stereo-chemistry  (that  is,  "solid  chemistry"), 
which  studies  the  molecule  in  its  three  dimensions 
and  is  now  achieving  undreamed-of  triumphs.  This 
new  chemistry,  of  which  the  great  representative, 
lately  dead,  was  the  Dutchman,  Van't  Hoff,  finds  its 
starting-place  in  Pasteur's  observations  upon  tartaric 
acid;  and  his  name  should  be  borne  in  mind  and  in 
grateful  remembrance  whenever  stereo-chemical  the- 
ory guides  the  expert  in  the  synthesis  or  creation  of 
valuable  new  compounds,  such  as  Professor  Ehr- 
lich's  invaluable  compound  of  arsenic,  called  Sal- 
varsan  or  "  606,"  or  any  of  the  recent  valuable  hyp- 
notic or  antiseptic  drugs.  It  may  make  all  the  dif- 
ference in  the  world,  or  rather,  in  the  body,  that  a 
compound  is  built  up  on  a  left-handed  rather  than  a 
right-handed  plan,  and  once  we  realise  that  our  vital 
processes  are  a  series  of  fermentations,  and  that  one 
and  the  same  ferment  may  destroy  a  right-handed 
compound  and  leave  its  mirror-image  untouched,  as 
Pasteur  showed,  we  shall  be  able  to  appreciate  thera- 
peutically the  possibilities  of  stereo-chemistry  at  their 
due  worth. 

But  now  let  us  consider  the  more  immediate  sig- 
nificance of  these  matters.  They  show  us  that  fer- 
mentation may  be  due  to  the  growth  and  life  and 


58  SURGERY  AND  SOCIETY 

chemical  activity  of  a  bacillus.  It  is  not  the  air 
that  causes  fermentation,  though  the  process  may 
be  arrested  in  materials  from  which  air  is  excluded. 
The  exposure  to  air  is  really  exposure  to  microbic 
infection,  and  the  fermentation  follows.  If  air  be 
necessary  for  fermentation  it  is  because  air  is  neces- 
sary for  the  growth  of  most  microbes,  but  it  is  the 
microbes  and  not  the  air  that  are  really  responsible. 

Pasteur  very  carefully  studied  this  subject,  and 
showed  that,  whilst  all  microbes,  like  all  living 
things,  require  oxygen  for  the  purpose  of  respira- 
tion, some  obtain  it  from  the  air,  whereas  others 
cannot  live  in  the  presence  of  air  but  obtain  their 
oxygen  from  their  food  —  the  oxygen-containing 
compounds  which  they  split  up  in  the  course  of  their 
lives.  The  air-needing  microbes  he  called  aerobic, 
and  the  others  anaerobic.  The  former  will  grow 
most  abundantly  upon  the  surface  of  any  culture- 
medium,  whereas  the  latter  will  only  grow  at  some 
distance  beneath  the  surface.  A  typical  instance  of 
the  anaerobic  bacteria  is  the  bacillus  of  tetanus  or 
lockjaw,  which  grows  in  the  soil,  and  may  thus  in- 
fect any  chance  wound  in  the  hand  of  a  gardener  — 
without  relevance  to  whether  or  not  the  wound  be 
in  the  space  between  the  thumb  and  first  finger,  as 
is  popularly  supposed.  But  the  great  majority  of 
wounds  infected  with  soil  fail  to  give  rise  to  tetanus 
because  the  microbe,  disliking  the  air,  flourishes  only 
several  inches  below  the  surface. 

Into  the  great  controversy  regarding  the  nature 
of  fermentation  which  followed  the  initial  observa- 
tions, there  also  entered  the  question  of  "  sponta- 


PASTEUR  THE  FORERUNNER  59 

neous  generation,"  or  the  possible  origin  of  living 
forms,  de  novo,  in  not-living  materials.  Pasteur 
and  those  who  worked  with  him  showed  that  certain 
conditions,  such  as  destroyed  life,  or  made  its  pres- 
ence impossible,  prevented  the  occurrence  of  fer- 
mentation even  in  the  most  fermentable  materials, 
no  matter  whether  they  were  favourably  situated 
otherwise  or  not.  They  might  be  kept  at  suitable 
temperatures,  and  might  be  separated  from  the  air 
only  by  a  mere  plug  of  cotton-wool,  which  freely 
admits  the  air  but  allows  the  passage  of  no  microbes; 
in  either  case  the  material  would  not  ferment  if  it 
had  previously  been  boiled  or  otherwise  treated  so 
as  to  destroy  all  the  living  microbes  within  it. 
Plainly,  therefore,  it  was  not  the  air  and  the  warmth, 
nor  both  together,  but  the  microbes  which  commonly 
gain  access  from  the  air  to  putrefying  or  fermenting 
materials,  that  are  the  vera  causa  of  the  phenomena. 

The  bearing  of  these  fundamental  experiments 
upon  the  problem  of  spontaneous  generation  is  evi- 
dent. The  materials  deprived  of  life,  or  sterilised, 
as  we  now  say,  remained  so  indefinitely,  provided 
that  no  new  life  could  gain  access  to  them;  and  this 
was  so  no  matter  how  suitable  for  the  composition 
or  generation  of  living  beings  these  materials  might 
be.  The  controversy  regarding  spontaneous  gen- 
eration is  not  in  the  judgment  of  the  present  writer 
by  any  means  closed,  but  these  facts  observed  by 
Pasteur  evidently  bear  upon  it. 

Of  course  a  great  deal  was  learnt,  in  the  course  of 
this  controversy,  regarding  the  vital  conditions  of 
microbes.     Only  by   experiment   can   we   ascertain 


60  SURGERY  AND  SOCIETY 

what  temperatures  microbes  will  survive,  or  succumb 
to,  and  what  chemical  substances,  in  what  propor- 
tions, will  arrest  their  growth,  and  so  act  as  preserva- 
tives of  fermentable  materials,  or,  to  use  the  modern 
term,  as  antiseptics.  It  was  in  the  course  of  this 
work  that  Pasteur  discovered  the  method  of  steril- 
ising milk  which  is  now  known  as  pasteurisation,  and 
consists  in  the  prolonged  employment  of  a  less  de- 
gree of  heat  than  will  be  effective  if  used  for  only  a 
short  time. 

There  followed  that  which  will  ere  long  abolish 
the  chief  evils  of  man's  physical  life.  The  chemist 
that  was  the  student  of  beer  and  silkworms,  became 
the  revealer  of  the  causes  of  most  diseases.  His 
first  triumph  in  this  direction  was  the  discovery  of 
the  anthrax  bacillus,  and  the  proof  that  it  is  the 
veritable  cause  of  the  disease.  All  subsequent 
bacteriology  builds  upon  the  foundations  laid  by  this 
incomparable  pioneer;  and  all  bacteriology  yet  to 
come. 

His  magnificent  researches  into  hydrophobia,  in 
which  one  complexity  after  another  was  successfully 
unravelled,  enabled  him  to  provide  a  remedy  for 
that  terrible  disease,  though  the  microscope  and  even 
the  ultra-microscope  have  hitherto  failed  to  reveal 
the  form  of  the  living  organism  which  causes  it. 
Much  more  important  were  the  indirect  and  sub- 
sequent revelations  involved  in  this  and  similar  re- 
searches; for  the  master  had  not  only  identified 
and  convicted  the  causes  of  disease,  but  had  thrown 
light  upon  those  vital  inter-actions  between  host  and 
parasite  upon  which  all  the  facts  of  immunity  and 


PASTEUR  THE  FORERUNNER  61 

susceptibility,  including  the  daily  miracle  of  natural 
recovery  from  infectious  disease,  depend.  Further, 
he  showed  how  these  processes  involve  notable  in- 
fluences upon  the  microbes  concerned,  so  that  their 
virulence  can  be  enhanced  or  attenuated  by  passage 
through  the  bodies  of  highly  susceptible  or  highly 
refractory  hosts.  From  these  initial  inquiries  have 
proceeded  the  recent  researches  to  which  we  owe  the 
antitoxin  of  diphtheria,  inoculation  against  plague 
and  typhoid,  the  serum  treatment  of  tetanus  and 
cerebro-spinal  meningitis  ("spotted  fever"),  and 
also  the  various  microbic  preparations  now  found  to 
be  of  value  in  the  treatment  of  so-called  "  surgical 
diseases." 

"  It  is  in  the  power  of  man,"  said  Pasteur,  "  to 
make  all  parasitic  diseases  disappear  from  the 
earth;"  and  the  time  has  already  come  when  we 
may  say  that  the  words  are  being  justified.  The 
parasitic  diseases  are  being  made  to  disappear  from 
the  earth,  and  the  twentieth  century  will  substantially 
achieve  the  consummation  devoutly  to  be  wished, 
for  which  the  nineteenth  and  Louis  Pasteur,  above 
all  other  men,  provided  that  knowledge  which  is 
power.  Since  Pasteur's  time  the  tropical  diseases 
have  been  investigated  on  his  lines,  and  their  ex- 
termination waits  upon  human  volition  alone.  We 
understand  and  can  control  cholera  and  plague, 
malaria  and  yellow  fever  and  sleeping-sickness. 
Pasteur's  greatest  pupil,  Robert  Koch,  found  the 
tubercle  bacillus  in  1881,  a  date  which  therefore 
marks  the  beginning  of  the  end  of  the  most  deadly 
of  all  diseases.     At  the  other  end  of  the  scale,  one 


62  SURGERY  AND  SOCIETY 

may  obtain  relief  from  even  the  "  common  cold," 
by  means  of  an  appropriate  serum  —  not  to  mention 
the  surgeon's  possibilities  in  remedying  the  nasal  er- 
rors which  encourage  the  micrococcus  catarrhalis. 
There  is  no  end  whatever  to  the  services  present 
and  to  come  of  this  saviour  of  mankind.  In  future 
chapters  we  devote  ourselves  to  one  only  of  them; 
one  only,  yet,  through  the  work  of  Lord  Lister,  a 
boon  to  countless  millions. 

Here,  therefore,  we  must  leave  this  great  spirit. 
His  memory  is  kept  green  in  Paris  by  the  Pasteur 
Institute,  where  the  cure  of  hydrophobia  is  insignifi- 
cant compared  with  its  ever-increasing  contributions 
to  our  knowledge  regarding  and  control  over  dis- 
ease. As  we  have  seen,  the  French  people  know 
something  of  his  greatness,  and  they  have  reason. 
As  someone  has  said,  not  even  Pasteur  himself  could 
restore  to  his  countrymen  the  cubit  which,  according 
to  the  inevitable  laws  of  heredity  and  selection,  was 
lopped  off  their  stature  by  the  Napoleonic  cam- 
paigns. Nor  can  the  disastrous  consequences  of 
war,  to  conquerors  as  well  as  to  conquered,  be  more 
forcibly  stated  than  by  saying  that  not  even  Pasteur 
could  remedy  them.  But,  as  Huxley  pointed  out, 
his  economic  services,  not  in  the  matter  of  the  vital 
industry,  which  is  the  making  of  men,  but  to  the  silk 
trade  and  so  forth,  sufficed  alone  to  pay  the  entire 
indemnity  of  the  Franco-Prussian  war.  So  stated, 
that  was  much:  relatively  to  the  whole,  it  was  noth- 
ing. 

We  see  in  Louis  Pasteur  the  perfect  type  and  fig- 
ure of  that  intellectual  passion  which  is  re-creating 


PASTEUR  THE  FORERUNNER  63 

the  world.  He  was  a  devout  Catholic,  the  solitary 
pre-eminent  student  of  nature  whom  that  faith  has 
contributed  to  the  world  in  three  centuries.  His 
was  a  Catholicism  universal  indeed;  not  in  local 
manifestations  alone  did  he  see  the  wonderful,  but 
everywhere:  "  Tout  est  miracle,"  was  his  verdict. 
That  may  easily  and  lightly  be  said  by  those  who 
have  thrown  no  light  upon  any  natural  event,  and  to 
whom  everything  is  miracle  on  the  familiar  princi- 
ple, omne  ignotum  pro  magnifico.  But  the  words 
mean  something  on  the  lips  of  a  Pasteur.  For  con- 
sider: We  may  say  that  the  facts  of  disease  and 
death  were  brought  by  him  from  the  realm  of  the 
supernatural  and  miraculous  into  the  realm  of  the 
natural  and,  therefore,  as  the  fool  hath  said  in  his 
heart,  the  non-miraculous.  Disease  and  death  were 
the  great  mysteries,  where  the  occult  held  sway. 
The  malign  and  mysterious  influence  of  the  moon 
caused  lunacy;  there  was  the  evil  eye  with  its  mor- 
bific powers;  in  fever  and  in  epilepsy  the  body  was 
possessed  by  demons,  for  the  expulsion  of  which  Pas- 
teur's Church  still  trains  exorcists;  tuberculosis  was 
the  "  King's  Evil,"  to  be  cured  by  the  "  sovereign 
touch,"  wherewith  the  descendant  or  representative 
of  Deity  could  heal.  Far  more  than  all  other  men, 
Pasteur  abolished  forever  these  superstitions,  and 
gave  us  natural  ideas  of  disease,  essentially  simple, 
intelligible,  convincing  to  common  sense,  capable  of 
logical  demonstration.  When  such  a  man  taught 
that  all  is  miracle,  natural  and  divine,  we  may  do 
well  to  take  heed. 

His  passion  was  for  knowledge  and  its  beneficent 


64  SURGERY  AND  SOCIETY 

power.  "  II  faut  travailler,,,  was  his  favourite 
phrase,  and  the  motives  behind  it  were  as  pure  and 
high  as  human  motives  can  be.  Here  was  the  pri- 
mary secret  of  his  greatness:  and  the  second  was  the 
patient,  faithful,  subtle,  inexhaustible  intellect  which 
framed  hypotheses  and  tested  them,  with  equal  fer- 
tility and  accuracy  and  resource. 

Only  once  in  many  generations  does  Life  produce 
a  Pasteur.  Not  by  wishing,  nor  by  trying,  can  any 
of  us  emulate  him;  not  yet,  if  ever,  can  Eugenics 
indicate  or  control  the  immeasurable  complexities  of 
biological  law  which  are  involved  in  the  genesis  of 
genius  such  as  his ;  nor  is  there  any  school  of  science, 
though  its  income  were  a  million  pounds  a  minute, 
which  can  produce  a  Pasteur  by  the  cunning  of  its 
curriculum  and  the  alchemy  of  its  professors.  But 
if  we  cannot  make  ourselves  into  Pasteurs,  nor  breed 
such  as  he,  nor  transmute  spirits  of  clay  into  spirits 
of  radium  in  any  of  our  laboratories,  at  least  we  can 
revere  and  follow  according  to  our  lights  the  few 
supreme  men  of  genius  who  make  the  progress  of 
the  world.  At  least  we  can  vow,  here  and  now,  that 
we  will  worship  no  more  false  gods  who 

"  Gather  and  squander,  are  raised 
Aloft,  are  hurl'd  in  the  dust, 
Striving  blindly,  achieving 
Nothing," 

and  that,  in  so  far  as  we  can,  we  will  make  available, 
for  mankind,  the  work  of  these  great  ones,  and  will 
do  our  utmost  to  discover  and  to  aid,  instead  of 


PASTEUR  THE  FORERUNNER  65 

flouting   and   deriding,   their   successors,   when   and 
where  they  may  appear. 

To  Pasteur,  it  seems  to  me,  we  may  most  justly 
apply  the  noble  words  written  by  Matthew  Arnold  to 
his  father.     For  his,  indeed,  was  one  of  those 

"  souls  tempered  with  fire, 
Fervent,  heroic,  and  good, 
Helpers  and  friends  of  mankind." 

And  of  the  few  like  him  may  we  say: 

"  Ye  fill  up  the  gaps  in  our  files, 
Strengthen  the  wavering  line, 
Stablish,  continue  our  march, 
On,  to  the  bound  of  the  waste, 
On,  to  the  City  of  God." 


CHAPTER  V, 

LISTER  INTERVENES 

Pasteur,  as  we  have  seen,  was  a  chemist  and  bac- 
teriologist, not  a  physician  or  surgeon,  though  he 
is  the  father  of  all  physicians  and  surgeons  worthy 
of  the  name  to-day.  His  great  initial  achievement, 
upon  which  all  his  contributions  to  disease  ultimately 
depended,  was  the  proof  that  fermentation  is  due  to 
the  presence  in  the  fermenting  material  of  certain 
living  microbes.  Fermentation  was  his  problem, 
and  he  solved  it. 

Now  the  surgeon's  problem  was  inflammation,  as 
we  have  already  seen.  Everywhere  it  appeared  in 
his  handiwork,  and  thwarted  his  best  efforts;  every- 
where the  imminent  certainty  of  it  forbade  him  to 
use  the  knife  except  as  a  desperate  remedy,  and 
scarcely  even  as  a  desperate  remedy  for  any  malady 
within  the  skull  or  chest  or  abdomen.  Everywhere 
inflammation  appeared  in  wounds  made  by  accident, 
whenever  these  wounds  communicated  with  the  sur- 
face, and  in  such  cases  the  surgeon  could  amputate, 
or  attempt  to  drain  the  inflammatory  products,  but 
failure  dogged  his  steps,  and  even  his  heroic  and 
desperate  amputations,  necessitated  by  inflammation, 
were  followed  by  it,  and  the  life  went  the  way  of 
the  limb.  The  new  era  waited  for  one  revelation 
only  —  the  nature  of  inflammation.     Given  the  so- 

66 


LISTER  INTERVENES  67 

lution  of  that  problem,  with  the  consequent  control 
of  the  surgeon's  great  enemy,  and  all  modern  sur- 
gery is  made  possible.  The  need  was  not  for  a  chi- 
rurgeon  or  manual  labourer  (of  however  high  a 
type),  but  for  a  pathologist. 

That  pathologist  was  found  in  the  young  surgeon, 
Joseph  Lister,  who  obtained  his  first  medical  quali- 
fication in  the  fifties  of  last  century.  Here  was  a 
reader  and  a  thinker,  not  impotent  to  perceive  anal- 
ogies, and  Pasteur's  revelation  of  the  microbic  ori- 
gin of  fermentation  set  Lister  speculating  whether, 
perchance,  inflammation  also  might  not  be  a  process 
of  fermentation,  set  up  in  living  tissues  by  microbes. 
For  if  this  were  so,  the  microbes  might  be  excluded 
or  killed,  and  inflammation  averted.  Such  was  Lis- 
ter's idea;  but  "  he  discovers  who  proves,"  and  Lis- 
ter proved. 

This  is  not  the  place  for  a  technical  account  of 
those  splendid  researches  upon  which  modern  sur- 
gical practice  reposes.  The  papers  containing  them 
were  collected  and  reprinted  a  few  years  ago  in 
commemoration  of  the  jubilee  anniversary  of  Lord 
Lister's  entry  into  the  medical  profession.  Our 
concern  here  is  to  gain  some  understanding,  as  we 
have  it  to-day,  of  the  processes  of  inflammation, 
which  introduce  us  to  some  of  the  most  romantic 
and  miraculous  accomplishments  of  the  body,  such 
as  only  a  Maeterlinck  could  adequately  describe. 

If  we  cut  a  piece  of  wood  or  paper  or  a  lifeless 
body,  the  cut  remains.  But  one  of  the  powers  which 
living  things  have  acquired,  under  the  control  of 
natural  selection,  is  the  power  of  repair  >. —  which,  in 


68  SURGERY  AND  SOCIETY 

lower  forms  of  life,  may  amount  to  complete  re- 
generation of  a  lost  member.  Our  bodies  are  in- 
capable of  reproducing  an  amputated  limb,  nay, 
more,  of  reproducing  a  single  sweat-gland  or  hair- 
follicle  in  a  damaged  piece  of  skin.  Regenerate 
they  cannot;  and  it  is  deeply  interesting  to  the  evo- 
lutionist to  consider  the  complete  loss  of  this  power 
in  the  highest  forms  of  animal  life.  But  repair 
they  can,  and  the  process  is  a  remarkable  and  beau- 
tiful one.  No  matter  where  the  site,  the  body  can 
only  produce  scar-tissue  or  its  equivalent,  whether 
in  the  skin  or  in  the  brain  or  anywhere  else;  but 
that  tissue,  though  incapable  of  exercising  any  but 
the  mechanical  function  of  repairing  the  bodily  con- 
tinuity, is  invaluable  in  that  capacity.  If  we  are  to 
live  our  lives  outside  of  glass  cases  we  imperatively 
require  this  power  of  repair;  and  even  in  such  a  case, 
the  internal  injury  done  by  a  rough  particle  of  food 
would  demand  the  power  of  repair  if  we  were  to 
maintain  our  lives. 

This  inherent  power  it  is,  of  course,  that  the  sur- 
geon depends  upon.  Ambrose  Pare,  the  great 
French  surgeon  of  the  sixteenth  century,  who  intro- 
duced the  use  of  the  ligature  to  tie  cut  arteries,  said 
of  one  of  his  successful  cases,  "  I  dressed  his 
wounds,  God  healed  him."  And  to-day  the  surgeon 
who  dresses  wounds  and  who  daily  and  unconcern- 
edly makes  them,  depends  upon  the  vis  medicatrix 
Natura  for  the  process  of  repair.  Without  this 
power  there  could  be  no  surgery  —  not  even  the 
simplest  amputation  nor  the  withdrawal  of  a  tooth. 

The  process  of  repair,  unhampered  by  vicious  in- 


LISTER  INTERVENES  69 

fluences,  is  simple,  rapid,  and  painless.  Those 
vicious  influences  are  chiefly  the  microbes  of  inflam- 
mation, as  we  shall  duly  see;  but  first  we  must  note 
that,  Listerism  or  no  Listerism,  microbes  or  no  mi- 
crobes, repair  is  a  vital  process  which  depends  upon 
the  health  of  the  living  cells  involved,  and  cannot  be 
successfully  effected  if  they  fail.  Thus,  for  in- 
stance, modern  surgery  knows  that  the  degenera- 
tion of  the  tissues  produced  by  alcoholism  interferes 
with  the  reparative  process,  and  that  the  adminis- 
tration of  alcohol  during  repair  also  retards  and  im- 
perils it.  Also  the  surgeon  may  decline  to  operate, 
in  such  cases  as  those  of  diabetes,  because  he  knows 
that,  even  though  he  excludes  all  microbes  from  his 
wound,  it  may  not  heal.  The  patient's  tissues  are 
vitiated  by  the  abnormal  chemistry  of  his  body,  and 
they  cannot  be  counted  upon  to  perform  their  indis- 
pensable share  of  the  operation,  however  perfectly 
the  surgeon  performs  his. 

Again,  there  is  the  remarkable  peculiarity  of  the 
body  chemistry  which  is  known  as  haemophilia  or 
the  "  bleeding  disease."  We  classify  it  amongst 
diseases  of  the  blood,  but  we  do  not  yet  know  its 
pathology.  Its  characteristic  is  that  the  normal 
power  of  the  blood  to  arrest  bleeding  —  the  "nat- 
ural arrest  of  haemorrhage  " —  is  absent  in  hemo- 
philic persons.  There  may  be  some  peculiarity  in 
the  body-chemistry  of  the  salts  of  calcium  or  lime, 
which  are  necessary  for  the  formation  of  the  fibrin- 
ferment,  that  is  produced  in  the  blood  when  a  vessel 
is  damaged,  and  ferments  "  fibrinogen,"  one  of  the 
blood  proteins,  in  such  a  way  as  to  solidify  it  and 


70  SURGERY  AND  SOCIETY 

cause  the  blood  to  clot  This  is  part  of  the  process 
of  repair,  and  without  it  there  could  be  no  surgery, 
nor  mankind. 

In  haemophilia  the  slightest  rupture  of  a  tiny  ves- 
sel, as  may  happen,  say,  in  a  sharp  movement  of  the 
knee,  will  fill  that  joint  with  blood:  the  extraction 
of  a  tooth,  or  even  a  violent  sneeze,  may  lead  to  a 
fatal  haemorrhage.  In  such  cases  the  surgeon  will 
not  operate;  nor  has  much  success  followed  the  ad- 
ministration of  certain  salts  of  lime  before  proposed 
operation  on  haemophilic  patients.  The  case  con- 
cerns us  here  only  because  it  illustrates  the  point 
that  what  surgery,  at  its  highest,  does,  is  to  provide 
good  conditions  for  the  body's  own  processes  of  re- 
pair and  defence.  In  haemophilia  one  of  these  is 
inherently  absent,  and  the  only  way  of  dealing  with 
this  extraordinarily  interesting  and  instructive,  but 
tragic,  malady  is  to  apply  to  it  the  principles  of  what 
I  have  called  "  negative  eugenics,"  forbidding  par- 
enthood to  those  who  suffer  from,  or  can  transmit, 
the  defect.  Haemophilia  is  not  only  unique  in  its 
hereditary  bearing  upon  the  possibility  of  surgery, 
but  it  is  also  a  striking  illustration  of  the  Mendelian 
law  amongst  ourselves.  The  defect  is  "  dominant," 
as  Mendel  taught  us  to  say,  in  males,  and  "  reces- 
sive "  in  females.  Thus  the  daughters  of  a  haemo- 
philic man  will  be  normal,  as  individuals,  but  yet 
abnormal  as  parents,  for  the  effect  will  reappear  in 
their  sons.  It  is  a  crime  to  bring  such  sons,  or 
daughters  who  may  bear  such  sons,  into  the  world. 

Apart  from  such  cases,  we  count  on  easy,  certain, 
rapid  repair,   or   "  healing  by  first  intention,"   in 


LISTER  INTERVENES  71 

wounds  which  have  a  fair  chance.  We  take  it  for 
granted,  a  mere  commonplace,  that  the  gap  in  the 
skin  when  we  have  cleanly  cut  a  finger  will  be  filled 
by  something  poured  into  it  from  the  neighbouring 
tissues,  that  young  blood-vessels  will  push  their  way 
into  this  material,  and  that  the  cells  of  the  surface 
will  multiply  and  go  gaily  to  meet  each  other  from 
either  side  over  this  foundation.  There  is  just  the 
very  slightest  increase  of  blood  in  the  site  of  repair, 
and  it  may  swell  inappreciably,  and  perhaps  during 
part  of  the  time  it  may  feel  ticklish,  but  that  is  all. 
And  if  the  edges  of  the  wound  have  been  suitably 
apposed  and  the  knife  has  made  a  clean  cut,  only 
the  narrowest  of  lines  will  remain  to  record  the  ex- 
traordinary feat,  as  it  really  is,  which  was  so  easily 
accomplished. 

But  in  too  many  cases  the  healing  does  not  thus 
proceed.  The  wound  becomes  inflamed.  That  is 
to  say,  it  becomes  swollen,  red,  hot,  painful.  There 
is  destruction  of  tissue,  or  of  something  else  —  as 
we  shall  see  —  so  that  the  wound  discharges  or  fes- 
ters. A  whitlow  may  illustrate  the  process  for  any 
of  us  at  any  time.  This  is  inflammation,  and  this, 
as  Lister,  reasoning  and  observing  from  the  work  of 
Pasteur  on  fermentation,  finally  showed,  is  due  to 
the  attacks  of  microbes  upon  the  tissues.  First  let 
us  consider  how  far  the  analogy  is  now  seen  to  be 
a  real  identity;  and  secondly,  let  us  endeavour  to 
understand  the  meaning  of  inflammation,  thus  in- 
terpreted. 

First,  then,  we  have  learnt,  in  more  recent  years, 
that  just  as  the  yeast-cell  exercises  its  power  by  a 


72  SURGERY  AND  SOCIETY 

not-living  ferment  which  it  produces,  so  also  the 
microbes  of  inflammation  produce  their  effects  not 
at  all  by  their  mere  mechanical  presence  in  the 
wound,  but  by  means  of  the  substances  they  produce. 
These  we  commonly  call  toxins  or  poisons,  and  they 
are  of  various  composition,  differing,  indeed,  with 
every  kind  of  microbe.  But  many  of  them  have 
now  been  proved  to  be  definitely  ferments,  as  much 
as  the  pepsin  of  the  stomach,  or  the  active  agent 
of  the  yeast-cell,  is  a  ferment.  The  analogy  or  par- 
allel between  fermentation  occurring  in  lifeless  ma- 
terial, and  inflammation  occurring  in  the  living 
body,  is  therefore  more  than  an  analogy  or  parallel ; 
and  the  Listerian  suspicion  is  more  justified  even 
than  the  success  of  Listerian  methods  could  ever 
prove.  For  just  as  the  vital  theory  of  fermentation 
proves  to  be  not  antagonistic  to  the  chemical  theory, 
since  the  vital  agents  effect  fermentation  by  the  pro- 
duction of  chemical  ferments,  so  the  phenomena  of 
inflammation  are  seen  not  merely  to  be  due  to  mi- 
crobes as  fermentation  is,  but  are  actually  proved 
to  be  due  to  fermentation  in  the  strictest  chemical 
sense  of  that  term.  Certain  of  the  facts  of  inflam- 
mation are  simply  facts  of  fermentation,  as  when 
we  find  that  many  materials  in  the  wound  are  di- 
gested, that  is  to  say,  fermented,  and  dissolved  by 
the  microbic  ferments,  and  contribute  to  the  dis- 
charge. The  case,  then,  is  definitely  proved,  and 
we  recognise  in  inflammation,  whether  of  a  wound, 
or  of  the  lungs,  or  of  the  appendix,  or  where  we 
please,  a  process  the  essence  of  which  is  fermenta- 
tion started  by  the  chemical  ferments  produced  by 


LISTER  INTERVENES  73 

living  microbes.  And  once  this  be  proved  —  nay, 
more,  once  it  be  even  suspected  —  plainly  the  sur- 
geon must  seek  to  destroy  and  to  exclude  microbes, 
as  Lister  proceeded  to  do. 

But  now  let  us  endeavour  to  interpret  inflamma- 
tion with  this  key.  The  phenomena  are  more  than 
we  observe  in  a  fermenting  fluid.  The  process  is 
occurring  in  a  living  tissue,  and  though  that  tissue 
may  be  dissolved,  and  even  be  warmed,  though  even 
gases  may  be  produced  in  it,  there  is  more  to  be 
said.  The  heat  and  the  redness  and  the  swelling 
(not  to  mention  the  pain)  are  more  than  can  thus 
be  accounted  for.  They  are  due  to  the  enormous 
access  of  blood  to  the  inflamed  part.  Why  this  ac- 
cess? It  is  in  order  to  repel  and  destroy  the  mi- 
crobes. In  other  words,  inflammation  is  a  symp- 
tom not  of  death  but  of  life,  it  makes  for  health,  it 
is  a  vital  stand  made  by  the  body  for  its  safety,  it 
is  not  a  disease  but  a  struggle  against  disease. 
Given  the  attack,  only  the  defence  can  save  us,  and 
inflammation  is  that  vital  defence.  The  attack  may 
be  so  severe,  the  intoxication  and  fermentation  and 
absorption  of  the  products  so  acute,  that  the  patient 
may  succumb  without  having  been  able  to  summon 
inflammation  to  his  aid,  as  in  what  has  sometimes 
been  called  fulminating  —  lightning-like  —  appen- 
dicitis; had  inflammation  occurred  it  might  have 
saved  him. 

Here  is  a  paradoxical  and  revolutionary  concep- 
tion, which  turns  all  previous  assumptions  upside- 
down,  and  which  by  no  means  all,  even  of  those 
whose  business  it  is  to  treat  inflammation,  have  yet 


74  SURGERY  AND  SOCIETY 

realised.  For  consider  one  of  its  corollaries.  Dur- 
ing the  course  of  inflammation  the  patient's  temper- 
ature is  commonly  raised;  alas  for  him  if  it  falls  low 
when  it  should  rise.  In  other  words,  fever  is  a 
symptom  of  inflammation.  Now  we  think  of  fever 
as  an  illness,  an  evil,  a  thing  to  be  counteracted. 
And  so  it  may  be  that  we  give  drugs  like  antipyrin 
and  acetanilid  and  their  allies  —  rank  poisons  one 
and  all  —  so  as  to  reduce  the  fever ;  which  they  do, 
but  anon  the  patient  dies.  Our  maltreatment  of  the 
case  has  been  due  to  our  misconception  of  the  facts 
before  us;  bad  practice  has  followed  from  bad  the- 
ory. And  though  practitioners  have  given  up  pre- 
scribing these  powerful  and  noxious  drugs,  which 
were  hailed  with  such  delight  on  their  introduction 
a  generation  or  less  ago,  they  still  abundantly  pre- 
scribe alcohol  for  inflammation  —  as,  for  instance, 
in  pneumonia  —  supposing  that  its  effect  upon  fever 
is  beneficial  to  the  patient,  though  it  is  indeed  pre- 
cisely the  reverse.  For  there  are  two  ways  of  low- 
ering fever,  which  differ  as  light  from  darkness,  one 
being  the  way  of  life  and  the  other  the  way  of  death. 
We  may  kill,  or  wash  away,  or  neutralise  the  agents 
of,  the  microbes  which  are  attacking  us;  or  we  may 
paralyse  the  defence,  of  which  fever  is  a  symptom. 
But  the  local  phenomena  of  inflammation  demand 
further  attention;  for  they  are  of  high  interest  and 
beauty  in  themselves ;  they  require  to  be  understood 
if  the  surgeon's  treatment  of  it  is  to  be  understood; 
and  of  course  he  has  abundant  occasion  to  treat  it, 
though  he  no  longer  initiates  it,  now  that  Lister  has 
provided  him  with  the  key  to  its  causation. 


LISTER  INTERVENES  75 

A  common  and  characteristic  phenomenon  of  in- 
flammation is  the  formation  of  a  creamy  fluid  called 
pus,  the  microscopic  and  chemical  composition  of 
which  is  of  extraordinary  interest.  Chemically  it 
consists,  if  we  could  completely  analyse  it,  of  the  mi- 
crobic  products  or  ferments  of  the  fermented,  dis- 
solved or  digested  substances  of  the  attacked  part, 
and  also  of  certain  chemical  substances  formed  in 
the  body  and  designed  to  destroy  or  devitalise  the 
microbes,  or  to  neutralise  or  split  up  their  ferments 
or  toxins.  Naturally  enough,  the  chemical  study  of 
this  subject  is  immensely  difficult;  and  the  facts  vary- 
in  almost  infinite  degree,  not  merely  according  to 
the  species  but  according  to  the  particular  strain  of 
microbes  present.  They  may  not  even  be  the  same 
for  any  two  patients;  but  the  foregoing  is  the  out- 
line of  them.  As  might  be  expected,  this  mixture 
is  poisonous,  sometimes  intensely  so,  and  the  surgeon 
often  gives  relief  and  saves  life  by  nothing  more 
than  providing  a  route  for  its  escape  from  the  body, 
instead  of  permitting  its  absorption  and  the  disas- 
trous and  often  fatal  consequences  which  follow 
therefrom. 

But  the  microscopic  examination  of  pus  is  more 
interesting  still.  For  we  find  that  it  is  crowded  with 
tiny  cells  which  may  be  divided  into  two  great  op- 
posing groups.  They  are  nearly  all  dead,  for  pus 
is  crammed  with  corpses,  and  they  it  is  that  make 
it  look  creamy  and  opaque.  They  are  the  slain  in 
this  conflict  between  the  body  and  the  invaders. 
Thus  in  a  drop  of  ordinary  pus  we  find  the  dead 
bodies  of  incredible  numbers  of  the  round  microbes 


76  SURGERY  AND  SOCIETY 

called  cocci.  These,  of  course,  are  the  fons  et  origo 
mali,  the  original  malefactors.  The  burglars  have 
entered  our  house  and  been  killed  on  the  premises. 
Their  discovery  in  pus,  and  the  proof  of  their  primary- 
causal  relation  to  the  whole  series  of  phenomena, 
is  the  cardinal  revelation  of  Pasteur  and  Lister  for 
the  surgeon. 

But  myriads  of  our  servants  have  been  destroyed 
in  repelling  the  attack;  and  the  tendency  of  the 
pus  to  escape  is  a  beneficial  attempt  to  rid  the  body 
of  the  corpses  of  burglars  and  servants,  now  equally 
objectionable.  These  brave  servants  are  the  leuco- 
cytes or  white  cells  of  the  blood  —  or,  rather,  as  it 
appears,  those  of  the  white  cells  which  are  in  a  par- 
ticular stage  of  their  individual  development  —  and 
they  have  died  in  vast  numbers  in  the  course  of  kill- 
ing the  microbes  which  now  share  their  grave.  The 
whole  process  is  so  extraordinary  and  so  significant 
not  only  from  the  surgical  but  also  from  the  purely 
biological  point  of  view,  that  we  must  look  at  it 
rather  more  closely;  none  the  less  because  the  prin- 
ciples here  illustrated  are  true  of  inflammation  in 
general,  whether  or  not  it  happens  to  be  of  a  kind 
accessible  to  the  knife.  In  pneumonia,  for  instance, 
just  the  same  drama  is  played. 

When  injurious  microbes  make  an  entry  into  a 
wound  or  otherwise,  the  whole  body,  as  a  single  and 
devoted  organism,  wholly  organised,  co-ordinated 
and  mobile,  devotes  itself  to  the  business  of  defeat- 
ing them.  No  portion  of  the  human  commonwealth 
is  out  of  touch  with  the  rest;  none  is  more  immedi- 
ately and  whole-heartedly  served  than   the   other. 


LISTER  INTERVENES  77 

The  danger  may  threaten  in  the  brain  or  the  valves 
of  the  heart  or  under  a  toe-nail,  the  same  devotion, 
sacrifice,  efficiency,  concentration  of  purpose  is  found 
in  every  case.  It  is  as  if,  in  human  society,  the  at- 
tacks of  microbes,  say  the  tubercle  bacillus,  were 
as  well  and  devotedly  fought  when  made  upon  the 
poor  as  upon  the  rich;  it  is  as  if  the  body  perceived, 
what  society  will  one  day  perceive,  that  it  is  a  whole, 
and  that  injury  to  any  part  of  it  demands  the  services 
of  all  the  others  in  their  interests  as  much  as  in  its 
own.  There  is  a  text  here  for  what  might  be  a 
great  and  is  certainly  a  much-needed  sermon.  The 
lesson  taught  by  the  body  whenever  a  corn  becomes 
inflamed  —  as  much  as  when  the  most  vital  and  dis- 
tinguished of  organs  is  threatened  —  must  yet  be 
learnt  by  whatever  existing  State  proposes  to  survive 
in  the  struggles  of  the  future. 

Let  us  observe  the  proof  that  the  whole  body  is 
concerned  in  such  cases.  It  is  not  to  be  found  con- 
clusively in  the  fever,  for  we  might  suppose  that  that 
was  merely  an  annoyance  inflicted  upon  the  whole 
by  the  disturbance  in  the  part.  Nor  is  it  to  be  found 
in  the  fact  that  there  is  a  great  abundance  of  white 
cells  in  the  area  of  battle,  for  these  might  merely 
have  been  arrested,  and  commanded  for  local  service, 
as  they  passed  through  the  injured  tissues.  No,  the 
convincing  proof  is  to  be  found  in  the  fact  that  the 
blood,  as  a  whole,  is  found  to  contain  a  vastly  in- 
creased number  of  white  cells.  Normally,  such  a 
bulk  of  blood  as  might  correspond  to  two  pins' 
heads  will  contain  some  eight  or  nine  thousand  of 
these  white  cells  (interspersed  among  the  four  and 


78  SURGERY  AND  SOCIETY 

a  half  to  five  millions  of  red  cells  whicK  find  room, 
and  room  for  usefulness,  in  the  same  small  space)1. 
But  in  the  special  circumstances  of  need  which  the 
assault  of  microbes  creates,  the  number  of  leucocytes 
in  such  a  space  may  be  raised  by  perhaps  as  many 
as  five  times  or  more.  Thus  countless  billions  of 
white  cells  are  rapidly  produced  and  poured  into  the 
blood-stream,  in  a  few  hours,  when  inflammation 
threatens  —  or,  rather,  as  we  now  see  we  should  say, 
when  inflammation  is  required. 

The  number  of  leucocytes  produced  in  this  reac- 
tion, which  is  called  leucocytosis,  varies  widely  in 
various  cases,  and  in  the  course  of  a  single  case. 
It  is  no  guide  to  the  site  of  the  injury,  for  the  whole 
body  is  equally  precious  to  itself;  but  it  is  a  guide 
to  (a)  the  numbers  and  virulence  of  the  invaders 
and  (b)  the  vigour  of  the  defence.  Thus  a  high 
leucocyte-count  may  be  a  sign  of  grave  infection,  or 
of  vigorous  protection;  and  if  a  low  count  be  found 
where  the  infection  is  evidently  serious,  the  patient's 
chances  are  bad;  whilst  a  rapid  fall  in  a  high  count 
may  be  welcome  if  it  means  that,  for  instance,  a 
surgical  operation  has  struck  hard  at  the  attack,  or 
unwelcome  if  it  means  that  the  patient's  powers  of 
resistance,  though  as  necessary  as  ever,  are  failing. 

Two  instances  may  be  cited,  from  vivid  personal 
recollection,  of  the  kind  of  fashion,  ever  being  ex- 
tended, in  which  such  facts  as  these  may  be  applied 
in  practice,  quite  apart  from  their  enormous  inher- 
ent interest.  Thus  a  house  surgeon  may  devote 
himself  to  making  a  blood-count,  as  it  is  called,  of 
a  patient,  every  four  hours,  day  and  night,  for  a 


LISTER  INTERVENES  79 

time,  in  order  to  know  whether  to  send  for  his  chief; 
for  the  patient  has  appendicitis,  and  if  the  local 
trouble  is  going  to  take  the  form  of  acute  inflamma- 
tion with  the  slaughter  of  many  leucocytes,  the  fact 
will  be  indicated  by  the  large  number  of  white  cells 
to  be  found  in,  for  instance,  a  drop  of  blood  ob- 
tained by  pricking  the  lobe  of  his  ear.  iWhen  leu- 
cocytosis  occurs,  therefore,  it  may  be  regarded  as  an 
indication  that  the  surgeon  should  operate;  whereas 
if  the  count  does  not  rise  it  may  be  hoped  that  care- 
ful nursing  —  commonly  called  "  medical  treatment," 
and  indistinguishable  therefrom  —  will  suffice  to  see 
him  cure  himself. 

Again,  the  formation  of  an  abscess  —  for  that  is 
what  it  amounts  to  —  demanding  the  surgeon's  in- 
tervention, may  be  indicated  not  only  in  the  case 
of  the  appendix  or  anything  like  it.  A  little  boy 
had  pain  in  his  thigh,  and  various  vague  symptoms 
which  could  not  suffice  to  indicate  the  nature  of  the 
malady,  and  certainly  would  not  sanction  so  serious 
an  operation  as  cutting  down  upon  the  thigh-bone. 
But  he  developed  leucocytosis  and  the  surgeon  ar- 
gued therefrom  that  there  was  pus-formation  going 
on  somewhere  —  doubtless  where  the  boy  felt  his 
pain  —  and  accordingly  he  operated.  Reaching  the 
bone  he  found  nothing  —  the  trouble  was  not  in 
the  covering-membrane  of  the  bone,  as  it  often  may 
be.  To  open  the  thigh-bone  and  find  nothing  there 
would  be  a  most  unsatisfactory  proceeding;  and  no 
surgeon  could  or  would  have  taken  this  very  serious 
course  without  due  warrant.  But  the  large  number 
of  white  cells  in  the  red  droplet  from  the  little  pa- 


80  SURGERY  AND  SOCIETY 

tient's  ear  had  to  be  accounted  for;  the  surgeon 
opened  the  bone,  and  found  therein  a  tiny  focus  of 
pus  —  which,  undiscovered,  might  have  spread  until 
the  boy  lost  his  limb  or  his  life.  To  me  the  striking 
of  that  hidden  spot  of  mischief,  revealed  by  count 
ing  shadowy  shapes  in  a  film  of  blood  under  a  micro- 
scope, was  a  moment  of  rapture;  how  glorious  that 
such  a  thing  could  be!  It  was  one  of  my  earliest 
experiences  as  a  student;  and  it  may  be  capable  of 
imparting  some  such  feeling  as  mine  to  the  present 
reader.  The  fault  is  his  or  mine  if  it  does  not;  for 
the  facts  are  very  good. 

We  may  ask  how  the  body  is  able,  in  such  cases,  to 
know  what  is  required  and  to  do  it.  Its  information 
is  derived  not  from  the  nerves  of  the  injured  part, 
but  from  various  chemical  substances,  poisons,  fer- 
ments, "  hormones  "  or  messengers,  and  what  not, 
which  leave  the  battlefield,  whatever  their  exact 
source,  and  are  conveyed  by  the  blood-stream  to  the 
various  places  where  the  white  cells  are  always  being 
made  —  the  spleen,  the  lymphatic  glands,  and  so 
forth.  Here;  by  the  just  and  subtle  chemistry  of  the 
body,  the  vital  processes  required  for  the  hasty  de- 
velopment of  extraordinary  numbers  of  leucocytes 
are  set  in  motion  or  accelerated,  and  the  new  cells 
are  poured  into  the  blood,  which  carries  them  quickly 
to  the  affected  part. 

They  reach  it  inside  the  blood-vessels;  and  of 
course  their  business  is  in  the  tissues,  outside  the 
blood-vessels.  They,  therefore,  have  to  disembark, 
so  to  say,  and  proceed  to  the  scene  of  action.  The 
general  slowness  of  the  blood-stream  in  the  neigh- 


LISTER  INTERVENES  81 

bourhood  permits  them  to  come  to  a  stand  against 
the  walls  of  the  thinner  vessels.  Here  they  smell 
the  battlefield.  The  imagery  may  annoy  the  reader, 
but  it  is  surprisingly  near  the  truth.  Smell  is  a 
chemical  sense,  and  a  contact  sense;  and  that  is  ex- 
actly the  sense  which  these  cells  and  their  like  pos- 
sess. Chemical  substance  produced  either  by  the 
microbes  or  the  affected  tissues,  or  the  interaction 
of  their  respective  products  —  for  this  whole  battle 
is  fought  with  chemicals  —  must  filter  through  the 
walls  of  the  blood-vessels  and  attract  the  leucocytes, 
which  "  sense  "  or  smell  them.  The  leucocytes  pro- 
ceed, by  slow  flowing  and  almost  wriggling  in  a 
very  slow  tempo,  to  travel  through  the  wall  of  the 
blood-vessel,  a  process  which  is  known  as  the  "  emi- 
gration of  the  leucocytes  "  or,  in  the  Greek,  their 
"  diapedesis."  In  this  fashion,  an  enormous  number 
of  leucocytes,  in  never-ending  succession,  reach  the 
actual  seat  of  the  microbic  invasion,  and  this  battle, 
conducted  as  it  is  by  the  throwing  of  chemicals,  then 
takes  place  at  the  closest  quarters. 

With  the  microscope  we  do  not  see  the  chemicals, 
of  course,  and  so  we  used  somewhat  to  misinterpret 
what  next  occurs,  not  realising  that  success  in  the 
chemical  battle  is  that  which  determines  the  bodily 
fate  of  the  combatants  —  and  of  the  body  in  which 
they  fight.  That  bodily  fate  is  remarkable  indeed. 
In  pus  we  find  a  multitude  of  dead  and  partially  dis- 
integrated leucocytes.  But  when  we  employ  suita- 
ble dyes,  especially  those  derived  from  coal-tar,  we 
can  so  stain  the  contents  of  our  microscopic  field  as 
to  show  that  often  one  or  more  microbes  are  to  be 


82  SURGERY  AND  SOCIETY 

found  enclosed  within  the  substance  of  a  leucocyte. 
Here  we  touch  upon  the  famous  work  of  Prof. 
Metchnikoff,  of  the  Pasteur  Institute,  the  most  illus- 
trious of  Pasteur's  disciples  in  pure  science  now  sur- 
viving, since  Robert  Koch  has  passed  away.  Fol- 
lowing in  his  observations  in  the  case  of  a  water-flea, 
Metchnikoff  ascertained  the  remarkable  function  of 
the  leucocytes  in  inflammation  —  and  in  other  con- 
ditions also.  He  proved  that  they  attack  and  eat 
microbes,  and  therefore  called  them  phagocytes  or 
eating  cells.  Thus  what  actually  happens  in  the 
course  of  inflammation  is  that  the  phagocytes,  hav- 
ing been  produced  in  large  numbers,  and  having  emi- 
grated from  the  blood-vessels  of  the  part,  attack 
the  microbes,  and,  if  possible,  eat  them  up.  The 
eating  up  is  not  an  accident,  and  it  is  not  an  invasion 
of  the  leucocytes  by  the  microbes.  Each  of  these 
possibilities  has  to  be  considered,  and  each  is  dis- 
proved. The  actual  ingestion  of  an  invader  can  be 
beautifully  observed  in  many  cases,  perhaps  the  most 
dramatic  being  that  of  the  malaria  parasite.  This 
is  not  a  microbe,  but  an  animal  parasite,  and  it  in- 
vades the  blood  itself;  but  these  differences  do  not 
affect  the  validity  of  the  illustration. 

A  drop  of  blood  from  a  malarious  patient,  kept  on 
a  warmed  slide,  will  show  the  actual  attack  upon  the 
invader  by  one  or  more  phagocytes  and,  perhaps 
after  half  an  hour,  the  enclosure  of  the  parasite  by 
the  enveloping  arms  (which  are  the  extempore-wise 
extended  body)  of  the  phagocyte;  until  at  last  the 
normal  quick  movement  of  black  particles  in  the 
malaria  parasite  ceases,  and  it  undergoes  disintegra- 


LISTER  INTERVENES  83 

tion,  tHe  particles  lying  scattered  in  the  body  of  the 
successful  phagocyte.  The  only  way  in  which  to  win 
this  battle  is  to  eat  the  foe  alive. 

Metchnikoff  believes  that  the  chemical  aspect  of 
the  question  redounds  no  less  to  the  credit  of  the 
leucocytes ;  in  other  words,  that  the  chemical  agencies 
which  render  the  microbes  eatable  are  produced  by 
the  leucocytes.  Many,  however,  and  most  notably 
Professor  Ehrlich,  the  greatest  student  of  immunity, 
believe  that  the  chemical  work  is  done  by  other 
cells,  probably  those  of  the  tissues  attcked,  and  that 
the  leucocytes  only  eat  the  slain,  or,  at  least,  mori- 
bund. Certainly  the  leucocytes  do  not  always  do 
their  work.  In  the  case  of  malaria  it  may  be  that 
the  presence  of  a  minute  proportion  of  quinine  in 
the  blood  renders  the  parasites  eatable,  and  that  this 
is  the  real  service  of  quinine  to  the  patient.  Cer- 
tainly we  know  that  there  are  times  when  leucocytes 
appear  definitely  to  decline  to  attack  the  invaders 
which  are  swimming  beside  them.  Other  evidences, 
to  which  we  can  scarcely  do  more  than  allude  here, 
suggests  that  an  essential  part  of  the  work  is  done 
otherwise  than  by  the  leucocytes.  Notably  in  tuber- 
culosis (including,  of  course,  the  many  tuberculous 
inflammations  with  which  the  surgeon  has  to  deal), 
there  appears  to  be  conclusive  evidence  that  the 
bacilli  are  first  prepared  or  "  cooked  "  by  substances 
which  are  therefore  called  "  opsonins,"  before  they 
can  be  eaten  by  the  phagocytes;  and  there  exists  an 
elaborate  technique,  chiefly  due  to  Sir  Almroth 
Wright,  whereby  there  may  be  ascertained  what  is 
called  the  "  opsonic  index  "  of  a  patient,  which  ex- 


84  SURGERY  AND  SOCIETY 

presses  his  state  of  resistance  in  terms  of  the  number 
of  bacilli  which  his  leucocytes  can  be  observed  to  in- 
gest within  a  given  time.  Whatever  the  clinical 
value  of  this  method  in  medicine  and  surgery  may 
prove  to  be,  the  facts  do  seem  to  indicate  that  the 
leucocytes,  for  all  their  pluck  and  sacrifice,  are  not 
the  sole,  and  may  not  be  even  the  essential  factors  in 
the  fight  against  the  microbes  of  disease. 

One  cannot  compend  a  treatise  on  inflammation 
within  these  limits,  nor  is  there  any  occasion  to  do 
more  than  state  the  essentials  as  Lister  and  his  fol- 
lowers have  revealed  them  to  us.  There  is,  how- 
ever, at  least  one  point  of  high  importance  to  which 
reference  must  be  made  before  we  consider  Lister's 
application  of  the  new  knowledge  to  surgical  prac- 
tice. 

In  some  inflammations  we  may  find  a  "  pure  cul- 
ture "  of  one  kind  of  microbe  only  —  such  as  the 
cocci  which  are  seen  in  bunches  and  called  staphylo- 
cocci, or  those  which  are  seen  in  chains  and  are  called 
streptococci.  Again,  in  other  kinds  of  inflammation, 
common  to  medicine  and  surgery,  we  may  find  the 
tubercle  bacillus  alone.  It  is  a  general  principle, 
to  which  there  may  be  exceptions,  but  are  none  of 
known  importance,  that  the  body's  chances  are  bet- 
ter when  it  is  attacked  by  only  one  kind  of  microbe. 
But  too  often  we  find  a  mixed  infection,  due  not  to 
simultaneous  attack  by  two  or  more  kinds  of  microbe, 
but  to  primary  infection  by  one  and  secondary  in- 
fection by  another.  This  question  of  mixed  or 
double  infection  is  doubtless  of  importance  in  a 
multitude  of  conditions,   as,   for   instance,   the  pus- 


LISTER  INTERVENES  85 

formation  in  the  skin  of  a  patient  who  has  first  been 
attacked  by  the  microbe  of  a  small-pox  (whatever 
that  may  be)  ;  and  in  the  terrible  inflammations  in 
the  throat  which  are  amongst  the  gravest  "  compli- 
cations," as  we  used  to  say,  of  scarlet  fever;  but 
there  is  one  case  of  such  high  and  widespread  and 
close-spread  importance,  to  be  seen  all  over  the  world 
and  thickly  everywhere,  that  we  must  specially  con- 
sider it;  not  least  because  multiple  daily  tragedies 
everywhere  follow  the  neglect  of  Listerism  in  this 
regard. 

Of  course  it  must  be  tuberculosis,  the  universal 
(and  universally  preventable)  disease,  to  which  we 
refer.  Now  to  consider  first  its  commonest  form, 
which  is  pulmonary  tuberculosis  or  consumption, 
physicians  have  learnt  that  the  difference  between  a 
simple  infection  of  the  lungs  by  the  bacillus  of  Koch, 
and  the  addition  of  a  secondary  infection  by,  for 
instance,  the  cocci  of  "  surgical  inflammation,"  may 
be  the  difference  between  life  and  death.  It  may  be, 
incidentally,  the  difference  between  losing  no  weight 
and  acute  emaciation,  between  normal  sleep  and 
intense  night-sweating;  perhaps  between  an  "op- 
sonic index  "  which  is  of  value,  and  one  which  is  of 
none  —  for  the  power  of  the  white  cells  to  eat  up 
tubercle  bacilli  may  avail  little  if  there  are  countless 
baleful  cocci  to  contend  with  also. 

Now  physicians  have  been  aided  in  their  study  of 
these  differences  by  the  most  salient  and  tragic  les- 
sons derived  from  the  contrast  between  the  good 
or  Listerian  and  bad  or  pre-Listerian  surgery  of 
"  surgical  tuberculosis."     For  the  tubercle  bacillus, 


86'  SURGERY  AND  SOCIETY! 

probably  swallowed  in  the  milk  of  tuberculous  cows, 
invades  the  lymphatic  glands  ("  glands  in  the  neck  " 
is  the  result)  and  the  joints  and  the  bones,  and  many 
other  parts  of  the  body;  and  here  the  surgeon  is 
often  called  upon  to  deal  with  the  consequences. 
Now  these  forms  of  tuberculosis  may  be  cured  by 
the  body,  aided  instead  of  thwarted  by  the  physician, 
just  as  pulmonary  tuberculosis  may  be.  On  the 
other  hand,  the  surgeon's  knife  may  be  invaluable  in 
giving  outlet  to  a  tuberculous  abscess  or  otherwise; 
or  it  may  seal  the  patient's  doom  by  producing  a 
secondary  infection. 

Thus  perhaps  the  commonest  form  of  surgical 
tuberculosis  is  that  found  in  the  lymphatic  glands  on 
either  side  of  the  neck.  These  may  recover  "  spon- 
taneously," as  we  say  — "  that  blessed  word  '  Mes- 
opotamia '  " —  or  they  may  be  bodily  excised  by  the 
surgeon,  or  they  may  be  opened  in  a  dirty  way  — 
and  when  the  surgeon  talks  of  dirt  he  means  dirt 
indeed  —  admitting  the  cocci  of  "  surgical  inflam- 
mation," and  the  mixed  infection  will  at  the  least 
involve  an  ugly  and  otherwise  avoidable  scar  in  a 
conspicuous  place,  and  at  the  most  may  be  the  be- 
ginning of  the  end.  Worse  still  is  the  everyday 
case  of  the  tuberculous  abscess,  derived  from  tuber- 
culosis of  the  spine,  which  has  been  opened  wher- 
ever it  has  pointed,  in  back  or  thigh,  by  a  dirty 
surgeon  who  should  be  dead,  has  become  the  subject 
of  mixed  infection,  and  will  never  cease  to  discharge 
until  it  has  killed  the  patient.  Yes,  indeed,  the  child 
has  had  treatment;  and  one  school  of  administrators, 


LISTER  INTERVENES  87 

fighting  against  school  clinics,  will  be  satisfied,  es- 
pecially if  a  certain  society  connected  with  charity 
provided  the  ticket  therefor;  but  Heaven  help  it, 
what  treatment? 

This  subject  cannot  here  be  pursued,  but  enough 
will  have  been  said  to  show  what  an  alliance  between 
invaders  means  to  the  body-politic.  One  kind  of 
enemy  may  be  countered  by  the  manufacture  of  ex- 
quisitely fitted  weapons  for  its  repulsion;  and  that 
is  the  rule.  But  it  is  also  the  rule  that  the  weapons 
so  exquisitely  fitted  for  one  enemy  are  impotent 
for  another  —  all  immunity  is  probably  specific,  as 
we  say  —  and  thus  a  secondary  infection  is  the  great 
disaster.  It  follows  that  the  surgeon  who  "  treats  " 
a  focus  of  tubercle  bacilli,  for  instance,  by  opening 
a  route  for  cocci  and  planting  them  there,  is  simply 
depriving  the  patient  of  his  one  chance.  Nay,  more; 
the  surgeon  may  have  done  well,  and  have  made 
an  exit  for  the  worthless  material  without  planting 
any  cocci;  but  what  of  the  days  and  weeks  during 
which  the  wound  is  dressed,  and  what  of  the  fingers 
which  do  the  dressing?  Truth  to  tell,  only  the  finest 
Listerian  nursing  can  do  this  work,  and  if  it  cannot 
be  guaranteed,  no  cleanliness  at  the  time  will  justify 
operations.  Alas,  much  more  might  be  said;  but 
school  clinics  are  coming,  seek  to  arrest  them  who 
may;  "anything  is  as  good  as  established,  when 
that  is  established  which  will  produce  it  and  continue 
it." 

We  have  run  on  rapidly  from  those  early  days, 
not  only  to  the  present,  but  even  to  the  near  future ! 


88  SURGERY  AND  SOCIETY 

Let  us  now  return,  and  observe  how  Lister  applied 
the  principles  of  the  new  knowledge,  the  present  out- 
lines which  we  have  briefly  reviewed. 

Let  us  consider  what  the  surgery  of  the  time  was, 
and  we  shall  understand  the  immediate  problem.  It 
was  not,  then,  essentially  a  question  of  performing 
some  constructive  operation  through  unbroken  skin, 
as  in  making  an  intentional  compound  fracture  in 
the  cure  of  knock-knee  —  a  beautiful  and  represen- 
tative instance  to  which  we  shall  duly  come.  On 
the  contrary,  in  those  early  days  the  problem  was 
to  deal  with  the  accidental  compound  fracture,  al- 
ready grossly  infected,  and  demanding  immediate 
operation,  as  compound  fractures  then  constantly  did. 
The  microbes  were  already  there;  and  the  problem 
of  destroying  them  was  more  cogent  than  that  of 
excluding  more.  "  Sepsis  "  was  present  and  an  an- 
tiseptic was  required;  such  an  antiseptic  being,  of 
course,  a  germicide,  on  the  theory  that  germs  were 
the  cause  of  the  sepsis.  Thus,  in  a  fashion  not  un- 
like that  of  Sir  James  Simpson  just  twenty  years 
earlier,  Lister  set  about  looking  for  some  suitable 
chemical,  fit  to  do  the  particular  deed  he  required; 
and  as  Simpson  found  chloroform  so  Lister  found 
carbolic  acid,  supplied  him  by  the  founder  of  the 
firm  whose  name  is  still  closely  associated  with  that 
most  celebrated  of  antiseptics.  If,  then,  carbolic 
acid  killed  germs,  and  germs  killed  the  patients,  car- 
bolic acid  should  save  the  patients.  And  it  did. 
The  crushed  legs  of  the  victims  of  street-accidents 
and  the  like  were  removed  as  formerly,  but  the  free 
employment  of  the   antiseptic   enormously   reduced 


LISTER  INTERVENES  89 

the  subsequent  mortality.  We  may  say  that  approxi- 
mately one  in  three  was  the  death-rate  after  major 
operations  —  mostly  amputations,  the  surgeon  being 
chiefly  a  "saw-bones" — 'before  those  new  days; 
instead  of  perhaps  one  per  cent,  nowadays.  The 
best  figures,  however,  are  those  of  most  recent  attain- 
ment; the  immediate  point  is  that  Lister's  earliest 
figures  under  the  new  method  were  a  most  notable 
contrast  to  the  old  ones.  It  is  true  that,  as  the  Times 
very  happily  put  it,  as  his  solutions  grew  weaker 
his  arguments  grew  stronger,  and  we  shall  later  dis- 
cuss the  meaning  of  this  paradox,  with  its  apparently 
disconcerting  criticism.  But  the  arguments  provided 
by  even  the  strong  solutions  were  strong  enough. 

There  were  no  half-measures  about  what  we  may 
now,  in  all  reverence  and  gratitude,  call  primitive 
Listerism,  as  it  was  practised  in  Glasgow  in  1868 
and  1869,  in  which  latter  year  Lister  exchanged  his 
chair  of  surgery  there  for  the  chair  of  clinical  surgery 
in  Edinburgh.  Considering  the  effect  of  even  mod- 
ern pure  carbolic  acid  in  high  dilution,  upon  the  skin 
and  tissues,  we  may  be  sorry  as  well  as  glad  for  every- 
one concerned.  What  fingers  the  surgeons  and 
dressers  must  have  had  in  those  days !  The  carbolic 
acid  was  most  freely  employed.  The  wound  and  the 
dressings,  the  instruments  and  the  surgeon's  and  as- 
sistants' hands  —  all  alike  were  treated  with  the  ut- 
most vigour  and  rigour.  The  thoroughness  was  splen- 
did, nor  without  it,  though  we  may  almost  feel  in- 
clined to  laugh,  should  we  have  had  the  thorough- 
ness, so  different  and  contrasted  in  detail,  of  to-day. 
Lister  advised  those  concerned  to  try  to  imagine 


go  SURGERY  AND  SOCIETY 

everything  —  every  surface,  animate  or  inanimate, 
everywhere  —  as  covered  with  wet  green  paint ;  and 
thus  one  would  avoid  casually  touching  one's  coat, 
or  a  chair,  or  adjusting  one's  eye-glasses,  or  touching 
any  surface  whatsoever  unless  it  had  first  been  most 
abundantly  treated  with  carbolic  acid.  The  "  green 
paint  "  idea  was  to  impress  upon  the  imagination  the 
ubiquity  of  microbes. 

But  even  when  all  surfaces  were  suspect  and  either 
avoided  or  deluged  with  poison,  there  remained  the 
air,  and  Lister  feared  that  also.  He  had  reason, 
for  even  if  he  had  surpassed  the  long-standing  belief 
that  the  air  is  the  cause  of  inflammation,  yet  the 
results  of  exposure  of  wounds  to  the  air  appeared 
evident,  and  it  might  well  be  that  the  air  contained 
the  peccant  microbes.  Let  us  remember  the  disease 
called  malaria  or  '"  bad  air,"  which  until  the  other 
day  was  believed  to  be  due  to  exposure  to  the  night 
air,  but  is  really  due  to  the  bites  of  infected  mos- 
quitoes contained  in  the  night  air.  Similarly  here, 
though  Lister's  work  had  acquitted  the  air  as  air,  yet 
there  were  the  possible  microbes  which  the  air  con- 
tained. Hence  he  employed  at  first  a  carbolic  spray, 
an  engine  designed  continuously  to  sprinkle  the  air 
in  the  neighbourhood  of  the  operation  with  carbolic 
acid,  and  so  "  wing  "  the  possible  microbes  with  its 
hail  of  deadly  drops.  Of  this  I  can  speak  only 
from  hearsay,  the  carbolic  spray  having  been  aban- 
doned long  before  my  student  days;  but  I  can  still 
laugh  at  the  tales  told  by  my  teacher,  Prof.  John 
Chiene,  of  those  old  days,  and  especially  of  one  occa- 
sion when  the  apparatus  broke  in  a  certain  well-re- 


LISTER  INTERVENES  91 

membered  theatre  (now  probably  condemned  on 
Listerian  principles)  and  a  stream  of  carbolic  acid 
made  for  the  passage  past  the  boots  and  the  com- 
ments of  the  Pioneer.  Merely  to  have  seen  the 
very  place,  and  to  have  learnt  from  the  lips  of  an 
illustrious  pupil,  is  to  know  in  some  measure  what 
words  like  "  progress,"  M  science,"  "  evolution," 
"imagination"  mean;  and  to  realise  how  tremen- 
dous a  thing  it  is  to  be  a  child  of  the  past  and  a  par- 
ent of  the  future. 

The  carbolic  spray  was  abandoned,  for  the  suf- 
ficient reason  that  as  good  results,  and  better,  were 
obtained  without  it;  and  the  experimental  evidence 
thus  showed  that  the  air  is  not  so  much  to  be  feared 
as  was  thought.  It  contains  microbes,  assuredly, 
but  commonly  not  the  microbes  of  surgical  inflam- 
mation; and  since  this  is  so,  the  manifold  disad- 
vantage of  the  carbolic  spray,  even  when  it  did  not 
burst,  sufficed  to  condemn  it.  But  whilst  we  laugh 
at  this  cumbersome  and  unnecessary  and  inconvenient 
device,  we  may  consider  that  the  air  which  leaves 
the  surgeon's  mouth  and  nostrils,  and  those  of  his 
assistants,  may  very  well  be  dangerously  laden, 
whilst  there  are  possibilities  of  dangerous  contribu- 
tions to  the  air  from  his  hair  —  and  beard,  if  a  mod- 
ern surgeon  permitted  himself  to  wear  one ;  but  these 
modern  priests  of  humanity  shave  for  sufficient  and 
evident  reasons.  Thus  the  idea  of  the  carbolic  spray 
is  a  sound  one;  and  the  surgeon  who  shaves,  and 
covers  his  nose  and  lips,  and  wears  a  cap,  is  simply 
doing  in  a  vastly  better  way,  and  without  disad- 
vantages to  the  patient,  and  to  his  technique,  what 


92  SURGERY  AND  SOCIETY 

the  carbolic  spray  sought  to  do  forty  years  ago.  To 
this  subject  we  must  return  in  a  later  chapter,  but 
we  could  not  record  the  abandonment  of  the  carbolic 
spray  without  noting  that  the  surgeon  of  to-day  does 
better  what  it  sought  to  do.  It  was  not  merely  su- 
perfluous ;  nor  was  Lister  anything  but  right  and  thor- 
ough and  fruitful  in  introducing  it. 

His  earliest  results,  which  would  of  course  horrify 
any  surgeon  of  our  time  to-day,  were  abundantly 
sufficient  for  their  day.  A  parallel  may  here  be 
drawn,  perhaps,  with  the  case  of  the  introduction  of 
inoculation  for  small-pox  by  Lady  Mary  Wortley 
Montague  in  the  eighteenth  century.  Inoculation 
was  dangerous ;  many  who  sought  its  protection  were 
killed  by  it;  but  people  hastened  to  avail  themselves 
of  it  notwithstanding.  We  look  at  modern  vaccina- 
tion, and  we  read  the  results  of  inoculation ;  and  then 
we  may  begin  to  realise  what  small-pox  used  to  mean. 
Similarly  we  look  at  contemporary  surgery,  we  read 
the  impression  made  upon  the  living  minds  of  the 
time  —  not,  of  course,  the  dead  ones  —  by  Lister's 
early  results ;  and  then  we  may  begin  to  realise  what 
surgical  inflammation  used  to  mean. 

There  were  dead  minds,  of  course,  for  the  body 
too  often  survives  the  soul,  as  Marcus  Aurelius  ob- 
served long  ago.  And  there  were  many  varieties  of 
perverted,  as  also  of  reasonable,  criticism,  some  of 
which  we  may  endeavour  to  consider  in  the  following 
chapter,  in  their  due  historical  place,  before  we  con- 
sider the  deeply  interesting  record  —  I  scarcely 
think  it  would  be  possible  to  make  it  uninteresting 
—  of  the  development  from  those  early  days  of  car- 


LISTER  INTERVENES  93 

bolic  acid  everywhere,  to  our  own.  But  here  we 
leave  this  chapter,  for  we  have  seen  the  beginning 
of  the  end  of  terrors  and  horrors  innumerable.  Lis- 
ter has  intervened. 

He  intervened  as  the  latest  representative  of 
knowledge  rather  than  opinion,  inquiry  instead  of  as- 
sumption, question  instead  of  acceptance,  action  in- 
stead of  inertia,  human  beneficence  instead  of  ac- 
quiescence in  a  Providence  which  is  incarnate  in  such 
as  he,  or  nowhere.  How  many  prayers  and  en- 
treaties, how  many  objurgations  and  curses,  how 
many  vainly  intercessory  sacrifices  of  the  living  to 
the  dead,  of  the  many  to  the  few,  of  the  young  to 
the  old,  how  many  superstitions  and  follies,  how 
many  quackeries  and  shams  and  apologies  and  lies, 
how  much  fruitless  love  and  hope  and  labour  and 
courage  and  dexterity,  how  innumerable,  unimagin- 
able a  multitude  of  lives  sacrificed  to  that  most 
jealous  of  gods  called  Nescience,  the  bloodiest  and 
greediest  Moloch  of  them  all,  how  many  poisoned 
mothers,  killed  by  the  act  which  launches  new  life 
into  the  world,  how  many  hideous  battlefields,  how 
many  infected  hospitals,  how  many  asylums  for  ma- 
ternity whence  none  but  the  babies  issued  alive,  how 
many  blinded  eyes,  blocked  ears,  maimed  bodies, 
compressed  or  poisoned  brains,  through  which  issued 
insanity  and  impotence  and  paralysis,  and  crime, 
how  many  more  evils  of  young  and  old,  rich  and 
poor,  wise  and  foolish,  dying  or  about  to  be  born, 
white,  black,  or  yellow,  innocent  or  guilty  —  had 
preceded  this  hour  which  announced  their  end. 
There  is  no  pen,  nor  ever  was,  nor  will  be,  that 


94  SURGERY  AND  SOCIETY 

could  do  justice  or  a  tithe  of  a  tithe  of  justice  to 
the  meaning  of  that  historic  moment  in  the  history 
of  mankind  when  the  slowly  but  surely  seminal  la- 
bours of  the  appointed  in  many  past  generations, 
hitherto  unavailing,  jeered  at  by  fools,  unknown  by 
the  crowd,  trivial  in  the  eyes  of  kings,  culminated 
for  the  saving  of  fools  and  crowds  and  kings  alike, 
in  Listerian  surgery. 


CHAPTER  VI 

THE  CRITICS 

"  The  Universe  has  need  of  him,"  was  the  reflection 
with  which  Marcus  Aurelius  used  to  fortify  himself 
when  some  apparently  superfluous  and  injurious  per- 
son had  tried  his  temper.  There  are  cases  in  which 
the  Aurelian  creed  is  of  faith  rather  than  of  reason; 
but  the  need  for  critics  in  science  is  indisputable, 
and  even  the  least  intelligent  and  most  unfair  may 
fulfil  their  humble  function.  In  science  we  can  take 
no  one's  word  —  least  of  all  in  matters  of  life  and 
death ;  nor  is  it  possible  to  inquire  closely  into  the  evi- 
dence for  any  scientific  statement,  without  throwing 
more  light  upon  the  subject. 

One  must,  therefore,  beware  of  bitterness  in  this 
chapter;  and  for  the  better  dealing  with  the  more 
important  critics  of  Listerism,  some  of  whom  have 
undoubtedly  been  potent  in  preventing  its  practice 
in  many  cases,  let  us  first  dispose  of  the  more  obvious, 
inevitable  and  dull  critics,  whose  race  is  now  entirely 
extinct  —  one  of  the  last  survivors  being  a  hospital 
surgeon  and  extra-mural  teacher  in  my  student  days, 
when  he  was  generally  known,  in  reference  to  his 
surgical  technique,  as  "dirty — " 

This  excellent  gentleman,  whose  surgical  creed 
was  thus  briefly  epitomised  by  his  pupils,  had  simply 
represented  the  consequences  of  that  transition  from 

95 


96  SURGERY  AND  SOCIETY 

the  dynamic  to  the  static  which  commonly  marks  ad- 
vancing years,  and  has  its  illustrations  in  every  organ 
and  function  of  the  post-mature  body.  He  and  his 
like  'had  done  with  change,  especially  change  in 
fundamentals;  and  even  though  their  teaching  func- 
tion should  have  kept  them  learners,  they  found  it 
hard  to  recast  all  their  ways  of  thinking  and  doing, 
and  acquire  a  new,  complicated  and  most  exacting 
technique  when  the  time  was  near  at  hand  for  them 
to  wield  a  bistoury  for  the  last  time.  In  this  par- 
ticular and  remarkable  epoch,  the  like  of  which  was 
never  seen  in  the  history  of  surgery,  nor  even  the 
substitution  of  the  ligature  for  the  red-hot  iron  by 
Pare 'furnishing  a  precedent  for  it,  we  must  admit 
that  Lister's  colleagues  were  overwhelmed  by  the 
force  and  beauty  of  his  demonstrations;  and  that 
the  new  method  triumphed  very  rapidly  wherever 
it  was  seen.  Almost  at  once,  Lister  was  asked  to 
Edinburgh,  at  that  time  the  leading  medical  school 
of  the  planet,  and  there  he  rapidly  advanced  his 
technique  and  won  over  nearly  all  his  colleagues. 
In  Denmark  and  in  France  his  methods  were  intro- 
duced by  one  or  two  keen  followers;  and,  at  last, 
through  the  personal  influence  of  one  who  knew  the 
meaning  of  his  work,  he  was  invited  to  London,  and 
established  Listerian  surgery  in  King's  College. 
London  should  not  have  lagged  behind  Edinburgh 
and  the  Continent ;  but  one  who  is  now  a  loving  Lon- 
doner must  admit  that  London  always  did  and  ap- 
parently always  will.  Yet  perhaps  that  last  clause 
is  scarcely  justified,  for  when  William  Harvey  dis- 
covered the  circulation  of  the  blood,  the  greatest 


THE  CRITICS  97 

physiological  discovery  ever  made,  he  "  fell  off 
mightily  in  his  practice,"  by  reason  of  his  fellow- 
practitioners'  opinion  of  him;  and  London  did  much 
better  than  that  by  Lister  —  when  at  last  it  discov- 
ered him,  his  fame  having  advanced  upon  this  well- 
entrenched  capital  from  every  terrene  quarter,  north, 
south,  and  east. 

On  the  whole,  then,  we  may  record  that,  such  was 
the  need  for  Listerism,  and  such  was  the  quality  of 
even  its  earliest  doings,  that  the  opposition  of  sur- 
geons themselves  —  by  which  I  mean  the  few  best 
surgeons  —  was  rapidly  conquered,  and  was  doubt- 
less of  value  as  discipline  and  education  to  the  pre- 
cious young  life,  the  leaves  of  which  are  now  for  the 
healing  of  all  nations. 

One  colossal  opportunity,  provided,  as  it  were,  at 
the  earliest  hour,  for  the  beneficence  of  Listerism, 
was  utterly  lost;  but  here  we  must  blame  not  so 
much  the  critics  as  the  dull,  the  deaf,  the  blind,  the 
null,  the  surviving  corpses.  It  was  not  because  Lis- 
terism was  effectually  —  or  even  ineffectually  — ■ 
criticised,  nor  because  its  earliest  results,  in  amputa- 
tions, were  not  only  too  relevant  to  the  opportunity, 
that  the  revelation  of  1868  and  1869  was  as  if  it 
had  not  been  in  the  Franco-Prussian  War  of  1870- 
187 1.  Merely  let  the  fact  be  here  recorded,  for  it 
is  indeed  part  of  history;  nor  can  anyone  who  has 
looked  at  the  inner  record  of  the  Russo-Japanese 
War  lightly  question  that  the  issue  of  the  earlier 
campaign  might  very  well  have  been  reversed  if  the 
French  military  authorities  had  employed  the  prin- 
ciples of  Listerism  —  to  which  the  countrymen  of 


98  SURGERY  AND  SOCIETY 

Pasteur  had  almost  some  prescriptive  right.  But 
however  that  may  be  —  and  I  dare  swear  the  reader 
has  little  idea  how  much  may  be  convincingly  said 
for  what  seems,  perhaps,  an  extravagant  thesis  — 
certain  it  is  that  the  individual  destiny  of  how  many 
scores  of  thousands  of  soldiers,  and  of  those  who 
loved  or  depended  on  them,  was  darkened  in  that 
terrible  war  when  Listerism  had  already  dawned 
and  might  have  lightened  it.  We  shall  return  to  the 
relations  between  modern  surgery  and  modern  war, 
but  the  tragedy  whereby  Listerism  was  in  time  yet 
not  in  time  for  the  Franco-Prussian  War  may  here 
be  insisted  upon.  And  here  we  may  leave  the  con- 
sideration of  the  mere  dullness,  apathy,  and  blindness 
which  Listerism,  like  every  other  new  thing,  how- 
ever good,  had  to  encounter. 

Turn  we  now  to  a  very  different  type  of  opposi- 
tion; one  which  thoroughly  vindicates  the  critic's 
general  claim  to  utility.  The  merely  dull  or  accus- 
tomedly  "  dirty  "  surgeons  need  be  no  further  con- 
sidered, for  their  results  were  according  to  the  seeds 
they  sowed  in  their  patients'  wounds,  and  the  im- 
mediate judgment  went  against  them.  But  there 
were  one  or  two  operators  of  a  very  different  class, 
above  all  Lawson  Tait  of  Birmingham,  whose  orig- 
inal work  on  the  frontiers  of  surgery  is  operative  at 
this  hour  and  will  always  be  remembered.  The  men 
in  question  not  merely  opposed  Listerism,  but  they 
opposed  it  with  the  best  kind  of  argument  —  good 
results  obtained  without  it.  As  we  shall  see,  they 
were  really  practising  what  was  not  far  from  the 
subsequent  development  of  Listerism;  but  the  future 


THE  CRITICS  99 

could  scarcely  then  be  foreseen,  and  the  contem- 
porary appearance  was  simply  that  of  a  controversy 
between  a  surgeon  who  employed  powerful  chem- 
ical lotions  and  sprays,  obtaining  notable  results,  and 
another  who  forwent  any  such  aids  but  did  not 
forgo  cleanliness  —  and  obtained  results  no  less  no- 
table. 

Lawson  Tait  must  have  been  an  exceedingly  fine 
operator,  bold,  rapid,  and  skilful.  His  work  lay  not 
with  horribly  septic  compound  fractures  and  their 
like  —  in  dealing  with  which  the  inadequacy  of  his 
methods  would  have  been  apparent,  for  he  had  noth- 
ing to  oppose  to  the  microbes  already  present,  and 
Lister  had  —  but  largely  with  operations,  of  an  ap- 
parently very  formidable  kind,  which  involved  open- 
ing the  body  in  cases  which  were  not  infected  or 
septic  at  all.  His  particular  province  was  in  the 
surgery  required  by  women,  and  we  now  know  that 
women  have  a  much  higher  degree  than  men  of  nat- 
ural resistance  to  the  attacks  of  microbes  in  the  ab- 
domen. Everyone  is  familiar  with  the  greater  lia- 
bility of  men  to  appendicitis;  but  it  is  still  more  note- 
worthy that  serious  microbic  invasion  of  the  peri- 
toneum, the  lining  membrane  of  the  abdomen  and 
its  organs,  is  much  less  dangerous  in  women  than  in 
men.  They  largely  decline  to  permit  more  than  the 
merest  beginnings  of  peritonitis,  and  they  often  re- 
cover, as  it  seems  almost  miraculously,  from  very 
grave  and  widespread  peritonitis.  Thus,  as  we 
have  since  learnt,  Lawson  Tait  had  an  enormous 
advantage  in  the  sex  of  his  patients,  whom  Nature, 
knowing   her   demands   upon   them,    has   made   so 


ioo  SURGERY  AND  SOCIETY 

remarkably  resistant  to  abdominal   damage  of  all 
kinds. 

Not  less  interesting  is  the  other  factor  which  ac- 
counts for  Lawson  Tait's  results,  and  which  helped 
him,  for  so  long,  to  achieve  notable  triumphs  with- 
out the  aid  of  carbolic  acid.  After  all,  though  mi- 
crobes are  everywhere,  those  which  the  surgeon  has 
reason  to  fear  are  not:  the  vision  of  "  green  paint " 
on  every  surface  is  exaggerated,  though  salutary. 
As  for  the  surfaces  which  are  almost  alone  to  be 
feared,  Lawson  Tait  and  those  who  were  of  his 
school  went  very  far  with  cleanliness.  "  Soap  and 
water  "  they  believed  in;  and  so  does  modern  sur- 
gery. My  old  teacher,  Dr.  J.  W.  Ballantyne,  once 
told  me  that,  when  examining  at  a  certain  most  an- 
cient and  illustrious  University  which  shall  be  name- 
less, he  used  to  ask  the  candidates  how  they  would 
sterilise  their  hands  before  the  performance  of  a 
surgical  operation,  and,  on  being  told  that  the  hands 
should  be  steeped  in  a  solution  of  carbolic  acid  — 
11  i  in  40  " — would  reply  with  the  by  no  means  im- 
pertinent question,  "  Have  you  never  heard  of  a 
nail-brush?  "  Now  Lawson  Tait  and  his  school  had 
heard  of  nail-brushes,  and  they  believed  in  soap  and 
scrubbing,  and  ever-flowing  water.  With  these  de- 
vices for  attaining  not  only  cleanliness  in  the  ordinary 
sense  but  also,  as  we  readily  see,  a  very  high  measure 
of  surgical  cleanliness,  which  is  absence  of  dangerous 
microbes,  and  with  their  operations  upon  the  pre- 
viously unbroken  and  thoroughly  washed  skin  of 
their  highly  resistant  female  patients,  whose  peri- 
toneums  and  white  blood  cells  were  usually  quite 


THE  CRITICS-  101 

equal  to  swallowing  up  a  few  chance  microbes  with- 
out any  appreciable  fuss  —  no  wonder  the  arguments 
of  Lawson  Tait  against  the  champions  of  antiseptic 
solutions  were  substantial  and  formidable.  Nor 
were  they  less  so  because,  as  we  shall  abundantly  see 
later,  these  solutions,  especially  as  they  were  then 
employed,  not  merely  killed  microbes,  but  also  killed 
and  weakened  those  cells  of  the  patient  upon  which 
the  great  business  of  destroying  microbes  and  of  re- 
pairing breaches  of  tissue  depends.  Now  that  the 
controversy  is  ended,  and  Lawson  Tait  has  gone; 
and  now  that  a  new  controversy,  most  interesting 
and  useful,  is  being  maintained  between  surgeons 
whose  practice  involves  more  chemicals  and  those 
whose  practice,  like  his,  involves  less  or  none  —  we 
need  not  grudge  him  the  praise  due  to  those  best 
friends  of  any  new  thing,  its  discerning  and  con- 
structive critics.  And,  verily,  it  would  be  worth 
while,  if  it  were  possible,  to  see  working  side  by  side, 
a  modern  ovariotomist,  practising  the  best  "  asep- 
tic "  methods,  which  we  shall  shortly  discuss;  and 
Lawson  Tait,  the  clean  critic  of  a  generation  ago. 
Both  parties  to  that  controversy  were  indeed  right, 
and  both  wrong ;  for  it  takes  two  halves  to  make  the 
truth. 

Finally,  and  at  inevitable  length,  we  have  to  con- 
sider a  very  different  group  of  critics,  who  have 
neither  skill  nor  knowledge  nor  judgment,  nor  any 
alternatives  to  that  which  they  condemn,  and  from 
whom,  except  by  repercussion,  has  never  yet  pro- 
ceeded any  advantage  to  man,  woman,  child,  or 
animal;  who,  themselves  powerless  to  save,  are  the 


IG2  '  SURGERY  AND  SOCIETY 

sworn  enemies  of  the  greatest  deeds  yet  done  by  man 
for  men.  Yet  we  must  distinguish.  When  we  have 
dismissed  with  loathing  those  who  oppose  vivisection 
without  personal  humanity  as  their  motive,  who  lie, 
traduce,  cheat  thousands  out  of  their  one  chance  of 
life,  and  seek  to  arrest  the  advance  of  the  most 
beneficent  forms  of  knowledge,  which  have  already 
saved  the  lives  and  limbs  and  ease  of  countless  mul- 
titudes of  men,  women,  children,  dogs,  cats,  horses, 
cattle,  grouse,  kings,  mothers,  savages,  animals  wild 
and  domestic  or  in  zoological  gardens  —  when  we 
have  rejected  these  for  the  worse  than  vermin  that 
they  are,  we  must  bow  before  the  exalted  and  in- 
estimable emotion  which  dominates,  if  it  also  deludes, 
the  honest  anti-vivisectionist.  The  leaders  of  the 
cause  may  doubtless  have  other  motives,  too,  for 
their  personal  credit  is  often  bound  up  with  their 
making  good  their  case ;  but  very  rarely  does  human 
conduct  proceed  from  one  motive  only,  and  we  are 
bound  to  admit  that,  on  the  whole,  the  emotion 
underlying  the  anti-vivisection  campaign  is  that  which 
opposes  alcohol,  which  freed  the  slave,  excluded  chil- 
dren from  coal  mines,  saves  the  life  of  every  baby 
that  survives  in  the  world.  It  is  the  pitiful  com- 
passion for  the  helpless,  derived  by  the  simplest 
of  transmutations  from  the  parental  instinct;  and 
since  the  existence  of  a  species  whose  individuals  are 
born  helpless  wholly  depends  thereon,  and  since  it  is 
the  source  of  all  the  best  in  our  nature,  we  are  ill- 
advised  to  despise  its  most  misguided  manifestations. 
I  vividly  remember  an  incident  at  a  meeting  which 
we  convened  in  London  not  so  long  ago,   for  the 


THE  CRITICS  103 

formation  of  a  society  to  destroy  rats  and  similar 
animals  which  convey  plague  and  other  diseases  of 
mankind.  Near  the  end  of  the  proceedings,  after 
some  of  the  most  eminent  medical  and  biological 
authorities  had  spoken,  a  brave  lady  made  a  protest 
against  cruel  agents,  and  a  plea  for  whatever  meth- 
ods of  destruction  should  be  most  humane;  and  very 
nearly  everyone  greeted  her  with  hearty  and  spon- 
taneous laughter.  There  was  nothing  whatever  to 
laugh  at.  She  was  pleading  for  life,  and  so  were 
we.  The  anti-vivisectionist,  who  hates  the  thought 
of  others  suffering  and  strives  to  prevent  it  in  his 
way,  are  both  actuated  by  one  and  the  same  noble 
emotion.  There  is  the  pity  of  it;  for,  as  Hegel  said, 
the  tragedy  of  the  world  is  the  conflict  not  between 
right  and  wrong,  but  between  right  and  right. 

It  is  a  tragedy  indeed  in  the  present  case.  Not 
merely  do  the  anti-vivisectionists  injure  those  whom 
they  seek  to  benefit,  animals  and  human  beings  alike; 
but  their  emotional  force,  their  courage  and  patience 
and  powers  of  persuasion  are  all  lost  to  the  very 
cause  for  which  they  are  really  striving,  and  which 
so  urgently  needs  them.  Consider  the  apathy  and 
stupidity  and  acquiescence  of  the  overwhelming  ma- 
jority of  mankind  in  all  classes;  their  callous  com- 
posure in  the  presence  of  the  preventable  ravages 
wrought  by  the  customary  evils  like  consumption  and 
alcoholism,  and  their  fatuous  fear  in  the  presence  of 
any  inconsiderable  novelty  with  a  startling  name, 
such  as  "  spotted-fever,"  or  the  accidental  occurrence 
of  arsenic  in  beer  —  as  if  beer  did  not  already  con- 
tain alcohol:  consider  the  measure  of  force  which  in 


104  SURGERY  AND  SOCIETY 

all  ages  is  demanded  of  the  few  who  feel,  wherewith 
to  animate  the  general  company  of  the  moribund, 
walking  blind  and  deaf  to  their  own  funerals;  and 
ask  whether  it  is  not  a  tragedy  that  any  iota  of  this 
precious  force  should  be  pitted  against  itself,  when 
the  present  and  posterity  are  dying  even  now  for  the 
lack  of  it.  There  is  the  pathos  of  this  pitiful  farce, 
upon  which  the  curtain  of  each  successive  year  rises, 
though  always  it  seems  as  if  it  could  last  no  longer. 

Here,  in  London,  are  Mr.  Sydney  Holland  and 
Mr.  Stephen  Paget,  for  instance,  doing  splendid 
work  for  their  hospitals,  each  in  his  own  way.  And 
here,  to  boot,  is  Mr.  Stephen  Coleridge,  also  a  hu- 
mane and  devoted  man,  related  in  name  and  blood 
and  feeling  to  the  poet  who  taught  us  in  the  "  An- 
cient Mariner  "  that  wilful  cruelty  to  anything  that 
lives  and  can  feel  is  a  foul  and  hateful  thing.  How 
many  London  hospitals  that  envy  the  London  Hos- 
pital its  treasurer,  notoriously  the  most  successful 
and  unintermittent  beggar  in  the  world,  would  be 
doubled  in  efficiency  if  they  could  obtain  the  similar 
services  of  Mr.  Coleridge?  Yet  instead  of  our  hav- 
ing these  three  men's  force  and  power  on  the  side 
of  humanity  and  progress,  year  in  year  out  we  see 
much  of  their  time  and  skill  and  force  mutually  an- 
nihilated —  Mr.  Holland  begging  for  the  hospitals, 
and  Mr.  Coleridge  begging  the  public  not  to  give  to 
the  hospitals,  and  Mr.  Paget  doing  his  splendid  work 
as  Honorary  Secretary  of  the  Research  Defence  So- 
ciety, formed  to  counteract  the  society  of  which  Mr. 
Coleridge  is  the  Honorary  Secretary:  and  all  three 


THE  CRITICS  105 

men  primarily  moved  by  the  same  high  and  precious 
emotion. 

Let  us  then  see  whether  a  further  statement  of 
the  case,  in  connexion  especially  with  the  genesis  and 
development  of  modern  surgery,  may  perchance  win 
over  for  any  branch  of  effective  humanity  even  one 
of  those  who,  at  present,  are  fighting,  as  I  believe, 
against  their  own  side.  Not  that  one  should  be  too 
sanguine.  Some  eight  years  ago  I  left  the  court, 
amongst  the  most  delighted  of  many  spectators,  after 
a  special  jury  had  awarded  £2000  to  Prof.  Bayliss  for 
Mr.  Stephen  Coleridge's  libel  upon  him  in  the  case 
of  a  certain  "  brown  dog  "  (which  died  a  merciful 
and  painless  death  under  chloroform,  such  as  any 
of  us  might  well  hope  for).  Those  two  thousand 
pounds  went  to  the  support  of  physiological  experi- 
ment in  University  College,  and,  therefore,  to  the  life 
and  health  of  many  men  and  dogs,  white  and  brown, 
yet  to  come.  But  great  was  the  error  of  supposing 
that,  for  this  country,  at  any  rate,  the  anti-vivisection 
crusade  was  at  an  end.  Nevertheless,  let  the  special 
facts  of  the  question,  as  they  bear  upon  our  subject, 
be  hopefully  stated.  And  let  them  be  prefaced  by  a 
notable  and  unchallengeable  dictum.  The  following 
quotations  are  extracted  from  the  Introduction  writ- 
ten by  Lord  Lister  himself  to  Mr.  Stephen  Paget's 
well-known  book,  "  Experiments  on  Animals."  The 
unexampled  authority  of  the  writer  should  be  more 
generally  known  than  it  is  to  be  on  the  side  of  hu- 
mane and  responsible  experiment  upon  living  ani- 
mals : — 


106  SURGERY  AND  SOCIETY 

u  Mr.  Paget  has  become  widely  conversant  with 
such  investigations  [*  researches  involving  experi- 
ments upon  the  lower  animals'],  and  has  been 
deeply  impressed  with  the  greatness  of  the  benefits 
which  they  have  conferred  upon  mankind,  and  the 
grievous  mistake  that  is  made  by  those  who  desire 
to  suppress  them. 

"  The  action  of  these  well-meaning  persons  is 
based  upon  ignorance  .  .  .  they  deny  that 
any  good  has  ever  resulted  from  the  researches 
which  they  condemn.  How  far  such  statements 
are  from  the  truth  will  be  evident  to  those  who 
peruse  this  book  .  .  .  from  the  discovery  of 
the  circulation  of  the  blood  onwards,  our  knowl- 
edge of  healthy  animal  function  has  been  mainly 
derived  from  experiments  on  animals. 

"  The  chief  bulk  of  the  work  is  devoted  to  the 
class  of  investigations  which  are  most  frequent  at 
the  present  day;  and  it  shows  what  a  flood  of 
light  has  been  already  thrown  by  bacteriology 
upon  the  nature  of  human  disease  and  the  means 
of  combating  it. 

"  The  chapter  on  the  Action  of  Drugs  will  be  to 
many  a  startling  disclosure  of  the  gross  ignorance 
that  prevailed  among  physicians  even  in  the  earlier 
part  of  the  last  century.  The  great  revolution 
that  has  since  taken  place  is  no  doubt  largely  due 
to  advances  in  sciences  other  than  Biology,  espe- 
cially Chemistry.  But  it  could  not  have  attained 
its  present  proportions  without  the  ever-increasing 
knowledge  of  Physiology,  based  on  experiments  on 
animals;  and  Mr.  Paget  shows  how  large  a  share 


THE  CRITICS  107 

these  have  had  in  the  direct  investigation  of  arti- 
cles of  the  Materia  Medica. 

"  The  concluding  part  of  the  volume  discusses 
the  restrictions  which  have  been  placed  by  the 
legislature  in  this  country  [Great  Britain]  on 
those  engaged  in  these  researches,  with  the  view 
of  obviating  possible  abuse.  Whether  the  Act  in 
question  has  been  really  useful,  whether  it  has  not 
done  more  harm  than  good,  by  hampering  and 
sometimes  entirely  preventing  legitimate  and 
beneficent  investigation,  I  will  not  now  discuss." 

All  the  principles  of  evidence,  credibility,  and  be- 
lief must  be  abandoned  if  this  considered  judgment  of 
Lord  Lister's  is  not  to  stand  against  that  of  Mr.  Cole- 
ridge, who  had  never  seen  a  vivisection  experiment 
in  his  life,  as  he  told  the  court  in  Bayliss  v.  Coleridge, 
or  of  Miss  Lind-af-Hageby,  whose  first  experience 
was  of  the  "  brown  dog,"  and  who,  going  to  be  hor- 
rified, was  most  successfully  horrified  —  by  happen- 
ings which  existed  only  in  her  mind.  Also  the 
words  quoted  should  abundantly  suffice  to  dispose  of 
the  very  few  and  insignificant  medical  men,  much 
quoted,  who  differ  from  Lord  Lister  in  this  matter, 
and  also  in  this  other  —  that  they  have  not  yet  added 
anything  of  any  worth  to  human  knowledge  or  prac- 
tice. 

But  we  began  by  admitting  that  no  one's  word 
can  be  taken  in  science;  and  though  the  verdict  of 
Lord  Lister  on  the  historical  facts  needs  no  recita- 
tion of  those  facts  to  support  it,  they  are  of  such 
high  interest  in  themselves,  and  they  introduce  us  to 


108  SURGERY  AND  SOCIETY 

the  so  tragic  fate  of  a  pioneer,  that  we  must  here 
review  them ;  nor  can  we  do  better  than  recall  Lord 
Lister's  own  narrative,  to  be  found  in  his  Huxley 
lecture  of  1900:  — 

"  After  being  appointed  to  the  Chair  of  Sur- 
gery in  the  University  of  Glasgow,  I  became  one 
of  the  surgeons  to  the  Royal  Infirmary  of  that 
city.  Here  I  had,  too,  ample  opportunities  for 
studying  hospital  diseases,  of  which  the  most  fear- 
ful was  pyaemia.  About  this  time  I  saw  the  opin- 
ion expressed  by  a  high  authority  in  pathology 
that  the  pus  in  a  pyaemic  vein  was  probably  a  col- 
lection of  leucocytes.  Facts  such  as  those  which 
I  mentioned  as  having  aroused  my  interest  in  my 
student  days  in  a  case  of  pyaemia,  made  such  a 
view  to  me  incredible ;  and  I  determined  to  ascer- 
tain, if  possible,  the  real  state  of  things  by  experi- 
ment." 

Now  observe  how  failure  followed  the  best  ef- 
forts until  experiment  revealed  the  truth.  Lord 
Lister  continued :  — 

"  While  these  investigations  into  the  nature  of 
pyaemia  were  proceeding,  I  was  doing  my  utmost 
against  that  deadly  scourge.  Professor  Polli,  of 
Milan,  having  recommended  the  internal  admin- 
istration of  sulphite  of  potash  on  account  of  its 
anti-putrescent  properties,  I  gave  that  drug  a  very 
full  trial  as  a  prophylactic.  ...  At  the  same 
time,  I  did  my  best,  by  local  measures,  to  diminish 


THE  CRITICS  109 

the  risk  of  communicating  contagion  from  one 
wound  to  another.  I  freely  employed  antiseptic 
washes,  and  I  had  on  the  tables  of  my  wards  piles 
of  clean  towels  to  be  used  for  drying  my  hands 
and  those  of  my  assistants  after  washing  them,  as 
I  insisted  should  invariably  be  done  in  passing 
from  one  dressing  to  another.  But  all  my  ef- 
forts proved  abortive;  as  I  could  hardly  wonder 
when  I  believed,  with  chemists  generally,  that 
putrefaction  was  caused  by  the  oxygen  of  the  air. 
"  It  will  thus  be  seen  that  I  was  prepared  to 
welcome  Pasteur's  demonstration  that  putrefac- 
tion, like  other  true  fermentations,  is  caused  by 
microbes  growing  in  the  putrescible  substance. 
Thus  was  presented  a  new  problem ;  not  to  exclude 
oxygen  from  the  wounds,  which  was  impossible, 
but  to  protect  them  from  the  living  causes  of  de- 
composition by  means  which  should  act  with  as 
little  disturbance  of  the  tissues  as  is  consistent 
with  the  attainment  of  the  essential  object. 
.  .  .  To  apply  that  principle,  so  as  to  ensure 
the  greatest  safety  with  the  least  attendant  disad- 
vantage, has  been  my  chief  life-work." 

It  is  for  us  particularly  to  notice  in  the  forego- 
ing that  Lord  Lister's  efforts  against  the  "  deadly 
scourge  "  (which  most  of  the  younger  generation 
have  never  seen)  failed  for  want  of  the  one  cardinal 
piece  of  knowledge  which  only  experimental  re- 
search —  so-called  "  vivisection,"  a  term  which  we 
should  use  only  if  we  remember  that  every  surgical 
operation  is  equally  and  similarly  a  vivisection  — 


no  SURGERY  AND  SOCIETY 

could  give.  There  was  no  question  that  putrefac- 
tion occurred  in  pyaemia,  nor  that  the  disease  was 
contagious :  than  those  two  facts  nothing  could  be 
more  appallingly  evident.  And  substances  were 
known,  as  they  always  have  been  known,  which  inter- 
fered with  putrefaction.  But  so  long  as  the  essen- 
tial cause  of  the  disease  remained  unknown,  the  best 
and  wisest  efforts  of  the  greatest  surgeon  of  all  time 
were  of  no  avail ;  whereas  no  sooner  had  experiment 
revealed  the  truth  than  surgery  was  transformed. 

A  point  worth  noting  before  we  proceed  is  that 
by  no  means  all  drugs  which  interfere  with  putre- 
faction and  claim  and  obtain  the  name  of  antisep- 
tics are  genuinely  germicidal.  The  test  for  putre- 
faction employed  by  the  ancients;  and  by  those  of  the 
ancients,  a  numerous  progeny,  who  still  survive,  was 
the  sense  of  smell;  and  to  this  day  anything  which 
paralyses  the  sense  of  smell,  or  overwhelms  it  by 
the  introduction  of  a  screening  odour,  or  absorbs 
the  malodorous  gases  of  putrefaction,  or  neutralises 
them  chemically  by  oxidation  or  otherwise  —  may 
be  looked  upon  as  an  antiseptic  though  it  really  does 
nothing  to  arrest  putrefaction,  much  less  to  kill  its 
living  causes  outright.  Hence  the  "  antiputrescent 
properties "  of  this  drug,  and  the  "  healthful  va- 
pours "  of  that,  or  the  "  deodorant  powers  "  of  an- 
other, or  the  "  fumigation  M  effected  by  a  fourth  — 
may  all  fail  and  did  all  fail.  But  to  find  and  convict 
the  cocci,  and  to  dose  them  with  carbolic  acid,  which 
kills  them,  was  to  make  a  new  earth  in  so  far  as  sur- 
gery and  maternity  and  much  more  are  concerned. 
And  the  opinion  of  those  who  did  this  work  is  not 


THE  CRITICS  in 

only  that  it  was  done  by  the  aid  of  experiment  upon 
animals,  but  also  that  it  could  not  otherwise  have 
been  done. 

One  most  tragic  and  instructive  episode  in  this 
brief  history  had  best  be  considered  when  we  come 
to  consider  the  services  of  Listerism  to  motherhood ; 
and  that  episode  will  show,  still  more  clearly,  that 
only  the  bacteriological  knowledge  which  experiment 
on  animals  affords  could  suffice  for  the  control  and 
ultimate  abolition  of  puerperal  fever,  the  great  en- 
emy of  maternity.  And  we  shall  see  that,  just  as 
Lister's  efforts  to  control  pyaemia  failed  until  the 
criminal  coccus  was  caught  and  convicted,  so  also  the 
efforts  of  his  predecessors  in  this  field,  Oliver  Wen- 
dell Holmes  in  his  manner  and  Semmelweis  in  his, 
without  their  due  fruition  because  the  bacterio- 
logical basis  was  lacking. 

Time  is  the  best  friend  of  truth,  and  its  verdict  in 
this  matter  is  no  longer  doubtful.  Before  bacteri- 
ology the  evidence  of  the  value  of  research  was 
clear;  but  in  our  own  time  it  is  everwhelming  and 
inexhaustible  and  infinite;  not  one  week  passes  but 
we  gain  new  knowledge  by  this  method.  Its  serv- 
ices to  animals  alone  are  incalculable;  for  every  dog 
which  breathes  chloroform  and  never  wakes,  many 
are  saved  from  pain  and  death  and  the  loss  of  limbs 
by  the  knowledge  thus  obtained. 

The  function  of  the  humanitarian  will  always  re- 
main. It  is  for  him,  whilst  no  longer  daring  to 
arrogate  to  himself  alone  the  possession  of  all  the 
tender  mercy  in  the  world,  nor  any  longer  lending 
his  voice  to  libel  and  slander  and  such  vile  sugges- 


U2  SURGERY  AND  SOCIETY 

tions  as  that  the  physiologist,  the  bacteriologist,  and 
the  surgeon  who  is  preparing  by  operation  upon  the 
lower  animals  (who  die  the  most  merciful  of 
deaths)  for  doing  his  duty  to  mankind,  are  secretly 
indulging  a  morbid  and  nameless  lust  —  it  is  for  him, 
surely,  to  keep  due  watch  over  the  risks  which  are 
involved  in  all  human  opportunity  and,  by  duly  ap- 
proving necessary  and  merciful  researches,  to 
strengthen  his  case  against  cruel  sports  and  against 
those  occasional  cases,  now  scarcely  if  at  all  paral- 
leled, where  some  Italian  physiologist  has  made 
experiments  on  pain  and  the  limits  of  its  toleration. 
Such  researches  are  loathsome  in  themselves  and 
wicked  in  their  consequences,  since  they  are  used 
potently  as  arguments  against  just  and  humane  in- 
quiry; and  it  is  to  be  hoped  that  Italy,  none  too  cel- 
ebrated for  kindness  to  animals  in  its  streets  and 
lanes  or  in  its  games,  may  soon  bring  its  standard 
of  research  upon  living  animals  up  to  the  high  Anglo- 
Saxon  level. 

Finally,  here  is  my  knee  to  the  noble  and  merciful 
ideal  which  inspires  those  against  whose  campaign 
this  chapter  is  a  protest.  They  demand  high  hon- 
our from  the  humble  historian  of  the  humanest  deed 
in  history. 


CHAPTER  VII 

THE  DEVELOPMENT  — ANTISEPTIC  AND 
ASEPTIC  METHODS 

We  now  come  to  a  most  interesting  chapter  in  the 
history  of  our  subject,  and  one  which  is  still  unfin- 
ished, for  Listerism  is  far  too  full  of  life  to  have 
ceased  development.  We  shall  see,  also,  that  the 
controversy  between  those  who  employ  the  anti- 
septic method  and  those  who  prefer  the  aseptic 
method,  is  by  no  means  a  matter  for  the  surgeon 
and  his  patients  only,  and  that  the  golden  mean 
which  will  win  the  day  at  last  is  applicable  not  only 
to  the  technique  of  the  surgical  theatre,  but  to  no 
less  important  a  question  than  the  preservation  of 
food  for  the  monstrous  cities  of  our  time,  forever 
crying,  "  Give,  give,  give,"  with  one  day  between 
them  and  starvation.  It  has  not  been  observed  that 
this  question  of  "  antiseptic  "  versus  "  aseptic  "  is  the 
same  question,  whether  we  are  discussing  the  prep- 
aration of  the  patient's  skin  before  a  surgical  in- 
cision, or  the  carriage  of  milk  to  nurse  him  back  to 
health  thereafter. 

We  must  go  back  to  first  principles  for  the  key  to 
the  facts:  for  they  depend  upon  the  circumstance 
that  all  life  is  one,  and  that  what  poisons  microbe 
poisons  man.  The  whole  truth  has  a  correlative 
half,  that  we  all  differ  and  that  one  man's  meat  is 

113 


ii4  SURGERY  AND  SOCIETY 

another  man's  poison,  which  is  true  of  microbes 
also,  and  represents  the  modern  and  future  principle 
of  poisoning  microbes  and  saving  patients  by  means 
of  specific  vaccines  and  sera.  But  here  we  are  con- 
cerned with  the  first  half  of  the  truth,  which  is  that 
many  substances  will  be  poisonous  to  all  or  prac- 
tically all  forms  of  life,  because  they  interfere  with 
fundamental  processes  shared  by  all  living  things. 
We  may  apply  the  name  of  protoplasmic  poisons  to 
all  substances  which,  in  suitable  circumstances,  are 
poisons  to  protoplasm,  "  the  physical  basis  of  life/* 
wherever  it  is  found.  Amongst  such  substances  are 
alcohol,  chloroform,  ether,  carbolic  acid,  arsenic, 
hydrocyanic  or  prussic  acid,  and  a  host  besides;  and 
they  definitely  belong  to  this  class,  for  good  bio- 
chemical reasons,  notwithstanding  the  fact  that  all 
of  them  may  on  occasion,  and  in  certain  ways,  be 
profitably  brought  into  medicinal  relation  with  liv- 
ing beings.  They  are  all  of  them  antiseptics,  of 
course,  for  nothing  can  live  in  the  presence  of  a  suf- 
ficient concentration  of  any  of  them,  though  alcohol 
has  the  distinction,  amongst  substances  of  this  class, 
that  the  bacillus  aceticus  lives  upon  it,  having  the 
power  to  decompose  it,  forming  acetic  acid;  and  that 
man  attempts  the  same  feat,  with  somewhat  less  suc- 
cess than  the  microbe. 

The  vinegar  microbe  apart,  alcohol  and  carbolic 
acid,  to  name  only  those  two,  are  powerful  anti- 
septics, but  the  properties  in  virtue  of  which  they 
kill  microbes  are  equally  lethal  to  living  cells  in 
general.  Carbolic  acid  effects  a  physical  change  in 
certain  proteins,  the  fluid  state  of  which  is  neces- 


THE  DEVELOPMENT  115 

sary  to  all  life  (for  all  life  is  lived  in  water), 
whereby  they  become  solid;  and  this  coagulation, 
which  kills  the  microbes  in  a  wound,  also  kills  what- 
ever living  cells  the  antiseptic  reaches  in  sufficient 
concentration,  and  weakens  many  more.  There 
may  well  be  other  chemical  explanations  of  the  con- 
sequences, but  there  is  no  doubt  as  to  the  general 
result.  The  inflammation,  as  we  have  seen,  is  a 
battle  between  two  sets  of  living  things :  the  carbolic 
acid  kills  both  indifferently,  and  the  same  is  true 
of  alcohol,  or  the  salts  of  mercury,  or  indeed  of 
antiseptics  in  general.  There  are  plenty  of  boasted 
antiseptics  which  do  no  injury  to  the  human  body, 
but  unfortunately  they  are  not  antiseptics,  or  they 
would. 

If,  now,  we  recall  the  elements  of  healing  and 
repair,  and  realise  that  the  body  heals  itself  if  it  is 
healed  at  all,  we  shall  be  ready  to  question  the  in- 
fluence of  our  undiscriminating  chemicals  upon  the 
permanent  necessities  of  the  patient's  welfare.  Evi- 
dently there  are  two  sides  to  the  question:  just  as 
there  were,  for  the  matter  of  that,  when  the  surgeon 
used  the  red-hot  iron  to  cauterise  a  dirty  wound. 
The  iron  killed  (as  we  now  know)  the  causes  of  the 
threatening  gangrene,  but  it  also  killed  much  of  the 
patient's  body;  and  though  the  result,  "  on  balance," 
was  often  to  the  patient's  credit,  the  dangers  were 
obvious.  The  carbolic  acid  and  the  cautery  are  very 
precisely  parallel  in  this  respect,  nor  can  the  case 
need  to  be  made  clearer,  save  only  to  say  that,  of 
the  two,  the  carbolic  acid  offered  a  far  higher  pre- 
ponderance of  advantage  to  the  patient,  especially 


n6  SURGERY  AND  SOCIETY 

as  its  use  in  weak  solutions  could  be  taken  advantage 
of  in  frequently  dressing  a  wound,  and  employing 
the  mechanical  virtues  of  irrigation.  But  let  us 
clearly  understand  that  the  use  of  a  general  anti- 
septic, which  kills  whatever  forms  of  life  it  en- 
counters, is  strictly  parallel  with  the  use  of  the  hot 
iron.  This  may  be  seen  even  more  clearly  if  we 
remember  that  concentrated  or  solid  carbolic  acid  is 
used  as  a  caustic,  and  a  very  good  one,  too,  by  sur- 
geons, and  may  in  various  instances  be  employed 
alternately  to  cauterisation  by  heat. 

The  local  employment  of  arsenic  —  the  deadly  ac- 
tion of  which  upon  nerves  is  known  to  all  who  boast 
bad  teeth  and  good  dentists  —  is  seen  in  the  u  can- 
cer pastes  "  which  used  often  to  be  employed.  The 
cells  of  the  cancer  may  here  be  taken  as  quite  par- 
allel with  the  microbic  cells  and  other  cases.  The  ar- 
senic may  kill  the  invading  cells,  but  the  objection  to 
its  use  is  that  it  does  more,  for  it  cannot  discriminate. 
Again,  in  various  forms  of  disease,  due  to  invasion 
by  a  microbe,  or  to  invasion  by  body  cells  turned 
traitorous  and  parasitic,  as  in  cancer,  we  may  em- 
ploy entirely  novel  forms  of  antiseptic  or  anti-para- 
sitic, such  as  radium  and  the  Rontgen  rays.  Here, 
also,  one  practical  difficulty  is  that  these  agents  do 
not  discriminate,  or  discriminate  imperfectly,  be- 
tween friend  and  foe. 

Enough  will  have  been  said  to  show  the  parallel- 
ism between  the  surgical  question  and  many  others. 
Let  us  now  examine  more  carefully  the  very  inter- 
esting objections  to  the  full-panoplied  antiseptic 
method. 


THE  DEVELOPMENT  117 

In  the  first  place,  we  are  dealing  with  a  poison 
which  is  to  some  extent  absorbed  by  the  body. 
There  are  plenty  of  cases  of  carbolic  acid  poisoning 
on  record,  where  the  patient  has  died  from  the  ab- 
sorption of  the  narcotic  drug  (as  it  is)  from  a  dress- 
ing. I  remember  seeing  such  a  case  as  a  student; 
and  realising,  as  never  before,  that  carbolic  acid  is 
a  double-edged  weapon  in  surgery.  Such  accidents 
are  scarcely  known  nowadays,  for  many  reasons,  in- 
cluding the  greater  purity  of  commercial  carbolic 
acid,  and  the  more  restricted  employment  of  what  is 
still,  and  probably  always  will  be,  one  of  the  most 
valuable  medicaments  in  the  world.  The  reader 
must  not  be  unduly  alarmed,  therefore,  nor  suppose 
that  carbolic  acid  is  not  safely  and  usefully  employed 
in  countless  cases  everywhere,  for  it  is  so  employed. 
But  the  fact  of  carbolic  acid  and  poisoning  will  help 
us  to  understand  the  more  recent  developments  of 
Listerism. 

Let  it  be  noted,  also,  that  the  various  anaesthetics, 
such  as  alcohol,  chloroform,  and  ether,  and  the 
A.C.E.  mixture  which  consists  of  these  three  in  cer- 
tain proportions,  are  all  poisons  as  well.  Thus  the 
patient  of  not  so  long  ago  might  be  receiving  large 
doses  of  two  deadly  poisons,  such  as  chloroform  and 
carbolic  acid,  simultaneously;  and  doubtless  many 
cases  of  so-called  "  surgical  shock "  were  cases  of 
poisoning  due  to  these  causes.  Recent  critical  in- 
quiry has  clearly  demonstrated  the  importance  of 
both  anaesthetics  and  antiseptics  as  general  or  con- 
stitutional poisons;  and  the  best  modern  surgery 
partly  owes  the  yearly  increasing  superiority  of  its 


n8  SURGERY  AND  SOCIETY 

results,  no  doubt,  to  its  careful  and  successful  atten- 
tion to  the  simple  principle,  not  fully  appreciated 
by  the  pioneers,  of  using  as  little  as  possible  of  these 
substances.  Modern  anaesthetics  delicately  gradu- 
ate their  dose  of  the  drug  or  mixture  of  drugs  that 
they  favour,  so  that  at  no  time  does  the  patient  get 
more  than  he  needs  at  that  particular  stage  of  the 
operation;  and  thus  the  total  dose  of  the  poison  is 
reduced  to  a  minimum.  But  not  so  long  ago  the 
anaesthetist  was  perfectly  content  to  keep  his  patient 
"  well  under,"  no  matter  how  deeply,  provided  only 
that  he  was  in  no  immediate  danger  of  ceasing  to 
breathe.  And  just  as  the  modern  anaesthetist  keeps 
down  the  dosage  of  his  poison,  knowing  that  it  must 
in  some  measure  affect  the  future  of  the  case,  quite 
apart  from  immediate  urgencies,  so  also  the  surgeon 
is  simultaneously  keeping  down  to  a  minimum  the 
carbolic  acid,  corrosive  sublimate,  and  so  forth,  with 
which,  in  past  days,  everybody  and  everything  con- 
cerned used  to  be  unintermittently  soused. 

The  constitutional  difference  to  the  patient,  after 
the  operation  is  very  great  indeed,  and,  speaking 
as  a  grateful  patient  myself,  I  can  testify  to  the 
advantage,  in  personal  feeling,  in  absence  of  nausea, 
in  rapidly  returning  appetite,  and  quick  recovery, 
which  largely  depend  upon  the  skilful,  which  is  also 
the  minimal,  employment  of  anaesthetics  and  anti- 
septics in  the  very  best  modern  surgery. 

There  is  yet  another  question  of  constitutional 
poisoning  to  consider.  Destruction  of  tissue  always 
means  constitutional  poisoning  by  the  absorption  of 
the  products  of  the  dead  tissue.     In  the  pathology 


THE  DEVELOPMENT  119 

of  burns,  surgeons  are  largely  agreed  that  the  sup- 
posed "  shock,"  which  so  often  kills  patients,  espe- 
cially children,  after  extensive  burns,  is  mainly  or 
largely  a  self-poisoning,  an  auto-intoxication,  due  to 
the  absorption  into  the  patient's  blood  of  the  decom- 
position products  of  the  skin  which  the  heat  has 
killed.  The  body  is  a  whole ;  as  we  must  remember 
for  its  own  understanding  and  for  the  understanding 
of  the  needs  and  the  ills  of  communities,  which  are 
organisms,  too.  The  destruction  and  death  of 
tissue  which  follows  upon  the  application  of  power- 
ful chemicals  like  mercuric  chloride  and  carbolic 
acid  leads  to  a  process  of  inevitable  auto-intoxi- 
cation, which  is  distinct  from,  but  accessory  to,  the 
poisoning  produced  by  absorption  of  the  antiseptic 
itself. 

Finally,  there  is  the  local  effect  of  the  chemical 
upon  those  delicate  young  cells  of  skin  and  deeper 
tissues  upon  which  the  process  of  repair  depends. 
We  have  seen  that  alcoholism  and  diabetes,  for  in- 
stance, impair  the  healing  powers  of  the  body,  and 
so,  as  we  might  well  expect,  does  the  local  and  im- 
mediate application  of  protoplasmic  poisons  to  the 
cells  upon  whose  behaviour  the  surgeon's  success  es- 
sentially depends.  To  take  one  instance  only,  con- 
sider those  tuberculous  inflammations,  where  bad 
surgery  has  incised  the  skin  and  introduced  a  second 
infection,  and  then  seeks  to  remedy  the  damage  by 
the  employment  of  antiseptics.  Poisoned  three  or 
four  times  over,  what  chance  have  the  miserable 
cells  of  the  part?  As  much  as  is  indicated  by  the 
fact   that,   under  such   conditions,   the   wound   will 


120  SURGERY  AND  SOCIETY 

never  close  until  the  patient's  life  has  drained  away 
through  it  —  nor  then. 

Such  are  the  numerous,  clear,  cogent,  and  com- 
mon-sense reasons  why  the  antiseptic  surgeon  ever 
aims  at  the  ideal  of  aseptic  surgery,  honouring  car- 
bolic acid  as  his  best  friend,  yet  seeking  to  use  as 
little  of  it  as  possible;  not  unlike  the  anaesthetist 
with  his  chloroform,  or  the  physician  with  his  qui- 
nine or  nux  vomica.  Can  it  be  believed  that  the 
anti-vivisectionists  have  asserted  the  evolution  of 
aseptic  from  antiseptic  surgery  to  be  an  abandon- 
ment of  Listerism  and  an  acknowledgment  of  the 
failure  of  that  which  was  claimed  for  a  triumph  of 
experimental  research?  Yet  that  is  what  has  hap- 
pened, and  it  is  the  reason  why  I  am  endeavouring 
in  this  chapter  to  state  with  special  care  the  rationale 
of  this  most  notable  and  most  beneficent  evolution. 
Many  surgeons,  not  least  of  them  Lord  Lister  him- 
self, have  declared  again  and  again  that  the  anti- 
septic method  has  never  been  abandoned,  and  that 
the  aseptic  method  is  only  a  refinement  of  it.  That 
most  obvious  fact  would  speedily  be  evident  to  any- 
one who  witnessed  a  modern  aseptic  operation,  for 
he  would  soon  discover  that  the  scrupulous  use  of 
powerful  antiseptics,  in  their  place,  was  an  essential 
part  of  the  technique.  What  that  place  is  we  shall 
duly  see.  And  though  Lawson  Tait  obtained  re- 
markable results  in  his  particular  field  without  the 
use  of  any  chemicals  but  soap  at  all,  yet  we  have 
seen  special  reasons  for  his  success,  and  it  may  be 
added,  first,  that  his  results  are  nothing  to  those  of 
to-day,  and  second,  that  of  course  he  employed  such 


THE  DEVELOPMENT  121 

antiseptics  as  heat  for  the  sterilisation  (as  we  know 
it  was)  of  his  towels  and  the  like. 

Let  us  then  see  what  the  distinction  really  is  be- 
tween these  two  forms  of  the  same  method,  of 
which  the  second  is  supposed  to  contradict  the  first 
by  persons  who  ought  really  to  avoid  supposing  any- 
thing. It  is,  above  all,  not  that  antiseptics  are  no 
longer  used  in  the  aseptic  method.  They  are  used 
differently.  First,  the  carbolic  spray  went,  unwept, 
but  neither  unhonoured  nor  unsung.  I,  for  one, 
here  honour  and  celebrate  the  ingenuity,  the  thor- 
oughness, the  courage,  and  the  scorn  of  mere  incon- 
venience to  his  dexterous  fingers,  which  went  to  the 
invention  of  the  spray  by  Lord  Lister.  Then  the 
powerful  solutions  became  weaker,  and  the  argu- 
ments, derived  from  the  results,  became  stronger,  as 
was  well  said  at  the  time.  And  all  the  while  bac- 
teriology was  steadfastly  pursuing  its  researches  into 
the  life  and  death  and  distribution  and  special  viru- 
lence of  microbes;  whilst  surgeons  were  beginning 
to  undertake  operations  on  the  unbroken  skin,  no  in- 
flammation being  present,  because  they  felt  reason- 
ably confident  that  they  need  leave  no  seeds  of  in- 
flammation behind  them. 

Now  in  such  cases,  evidently  there  does  not  exist 
the  same  need  to  deluge  the  patient's  tissues  with 
chemicals  as  in  the  already  infected  cases  to  which 
the  antiseptic  method  was  first  applied.  And  when 
it  was  realised  what  were  the  effects  of  these  chemi- 
cals, in  these  cases  where  their  germicidal  power 
was  useless,  in  the  absence  of  germs  to  Icill  —  sur- 
geons began  to  argue  that  better  results  should  be 


122  SURGERY  AND  SOCIETY 

obtainable  in  such  cases  if  the  antiseptics  were  kept 
away  from  the  patient's  tissues  altogether.  And 
that  is  aseptic  surgery ;  the  word  aseptic  meaning  not 
"  without  antiseptics,"  as  the  anti-vivisectionists,  in 
defiance  of  obvious  etymology,  suppose,  but  without 
sepsis  —  an  achievement  indeed. 

Far  more  formidable,  various  and  efficient  are  the 
antiseptics,  employed  in  modern  aseptic  Listerian 
surgery,  than  those  of  the  earlier  days.  The  pa- 
tient's tissues  are  sacred,  and  the  ideal,  when  they 
are  uninfected,  is  to  keep  them  so,  and  being  so,  free 
from  the  necessity  of  any  contact  with  antiseptics. 
But  if  this  is  to  be  effected  successfully,  there  must 
be  no  error,  no  lack  of  thoroughness,  in  the  anti- 
septic precautions  (for  that  is  what  they  are  in  such 
cases)  taken  everywhere  else.  For  there  is  an  evi- 
dent element  of  hazard  in  this  refinement,  unless  our 
technique  be  very  perfect  and  very  systematically 
checked.  A  few  microbes  left  on  the  surgeon's  fin- 
gers, or  otherwise  accidentally  conveyed  to  the  pa- 
tient, might  matter  little  if  vigorous  antiseptic  solu- 
tions preceded  and  followed  them  there.  But  if  no 
antiseptics  are  to  reach  the  patient,  certainly  no 
microbes  must,  or  they  will  flourish  unantagonised 
—  as  in  the  good  old  days,  with  their  uproariously 
jolly  death-rate,  before  science  (which  is,  being 
translated,  knowledge)  began  to  desiccate  the  world 
and  disgust  Mr.  Chesterton  and  other  champions  of 
nescience. 

If  there  is  to  be  no  doubt  about  the  sterility  of 
whatever  touches  the  patient,  we  must  not  have 
instruments  or  apparatus  the  complete  disinfection 


THE  DEVELOPMENT  123 

of  which  cannot  be  assured.  Sponges  must  disap- 
pear from  the  operating  theatre,  and  gauze  swabs, 
treated  with  superheated  steam  and  used  once  only, 
must  replace  them.  Instruments  such  as  scissors 
must  be  taken  to  pieces,  for  more  certain  cleaning. 
The  prolonged  application  of  high  temperatures  must 
be  used  for  whatever  will  not  thereby  be  destroyed 
—  such  as  the  surgeon's  hands.  The  steam  steriliser, 
best  of  antiseptics,  becomes  an  indispensable  part  of 
every  operating  theatre.  Antiseptic  solutions  of  va- 
rious kinds  are  employed  for  the  safe  preservation 
of  whatever  the  surgeon  may  require;  instruments 
and  water  are  boiled.  All  these  active  antiseptic 
precautions  are  for  the  performance  of  an  aseptic 
operation.  Antiseptics  of  various  kinds,  together 
with  alcoholic  soaps,  are  employed  to  disinfect  the 
patient's  skin  for  several  hours  before  the  opera- 
tion. They  sterilise  the  surface  layers,  somewhat 
deeper  than  those  which  are  removed  whenever  the 
skin  is  washed.  It  is  in  these  layers  that  microbes 
are  to  be  found.  Beneath  them  are  the  living  cells 
of  the  skin,  vital  for  healing,  and  they  are  not 
reached  by  the  antiseptic,  nor  do  they  need  to  be. 
The  positive  scrubbing  of  the  skin  with  antiseptics, 
which  thus  reach  the  deeper  living  layers,  is  still 
largely  practised,  but  involves  infraction  of  the  prin- 
ciple that  the  patient's  tissues  shall  not  be  devital- 
ised by  chemicals,  and  the  evidence  seems  clearly  to 
show  that  it  is  not  necessary  if  the  superficial,  in- 
fected layers  are  soberly  -treated  with  antiseptics  for 
several  hours.  Lord  Lister  himself  has  declared 
that  the  positive  and  continued  scrubbing,  so  as  to 


i24  SURGERY  AND  SOCIETY 

reach  the  living  skin,  is  not  necessary.  At  the  oper- 
ation, boiled  water  —  to  which,  perhaps,  a  small  per- 
centage of  common  salt  has  been  added  so  as  to 
make  it  comparable  in  its  physical  properties  with 
the  fluids  of  the  body  —  is  alone  allowed  to  touch 
the  patient.  The  surgeon's  fingers  and  everything 
else  that  has  been  in  an  antiseptic  are  rinsed  in  such 
water,  so  that  the  vis  medicatrix  Natura  is  given  a 
perfect  chance,  uncomplicated  by  local  or  general 
poisoning,  or  by  self-poisoning  that  follows  on  local 
destruction  of  tissue. 

Much  the  most  difficult  problem  remains,  which 
is  that  furnished  by  the  surgeon's  own  fingers,  and  is 
equally  serious  whether  an  antiseptic  or  aseptic  op- 
eration is  to  be  performed.  His  fingers  cannot  be 
put  into  the  steam  steriliser,  nor  boiled,  nor  kept  in 
glass  cases  when  he  is  not  operating.  Some  sur- 
geons operate  in  india-rubber  gloves,  whilst  others 
find  them  intolerable.  The  evidence  seems  to  show 
that  the  fingers  can  be  effectively  cleansed  by  the  fol- 
lowing of  a  careful  and  complicated  technique,  in 
which  soap  and  alcohol,  ether,  turpentine,  the  nail- 
brush and  carbolic  acid  may  all  play  a  part.  The 
surgeon's  fingers  may  receive  as  powerful  and  pro- 
longed a  soaking  in  antiseptics  as  they  and  he  will 
stand.  It  is  not  they  that  have  the  after  problem  of 
problems;  and,  if  the  antiseptic  is  washed  off,  the 
patient's  skin  will  not  be  disturbed  by  the  rigour  of 
the  processes  to  which  the  surgeon's  skin  has  been 
subjected. 

Plainly  nothing  short  of  inexcusable  ignorance  or 
still  more  inexcusable  dishonesty  can  account  for  the 


•       THE  DEVELOPMENT  125 

description  of  this  method  as  in  any  sense  whatever 
anything  but  the  perfecting  and  refining  of  antiseptic 
surgery  —  which  is  declared  by  its  inventor  and 
demonstrated  by  the  facts  to  be  a  direct  consequence 
of  experimental  research  upon  the  lower  animals. 

Some  further  points  of  great  interest  remain  to 
be  considered.  In  the  first  place,  there  is  the  ques- 
tion of  testing  and  checking  the  technique  upon 
which  so  much  depends.  In  the  leading  hospitals 
this  is  often  now  regarded  as  an  essential  part  of  the 
equipment  and  practice  of  surgery.  A  bacteriolog- 
ical laboratory  is  attached  to  the  surgical  depart- 
ment, and  performs  invaluable  functions,  of  daily 
increasing  importance.  It  is  obvious  that  all  man- 
ner of  diagnosis  will  depend  upon  the  findings  of 
this  laboratory,  and  diagnosis  by  surgical  procedure 
—  the  making  of  a  "  diagnostic  incision  " —  is  now 
an  everyday  proceeding:  made  perfectly  legitimate 
by  the  Listerian  methods  which  safeguard  the  sub- 
sequent healing.  But  here  I  wish  merely  to  refer 
to  the  uses  of  the  laboratory  in  connexion  with  the 
aseptic  method.  The  routine  may  be  for  the  steam 
steriliser  and  sterilisation  to  be  entrusted  to  a  par- 
ticular person,  any  of  whose  work  may  be  at  any 
moment  checked  by  the  sending  of  a  swab  or  what- 
not to  the  laboratory  to  see  if  any  form  of  life  can 
be  found  in  it.  Similarly  the  surgeon  will  test  and 
check  the  preparation  of  the  patient's  skin  and  of  his 
own,  not  to  mention  the  sterile  water  and  other  asep- 
tic but  not  antiseptic  fluids  employed  —  by  sending 
scrapings,  samples  of  dressings  and  so  on,  whenever 
he  will,  to  the  laboratory.     And  subsequently  it  may 


i26  SURGERY  AND  SOCIETY 

be  possible  for  such  a  surgeon  to  demonstrate  the 
effectiveness  of  his  technique  and  place  its  advan- 
tages at  general  disposal,  by  publishing  results  to 
show  that,  say,  during  an  entire  year,  or  in  a  series 
of  one  thousand  consecutive  operations,  bacterio- 
logical examination  of  this  kind  has  proved  that  no 
living  microbes  were  present  where  they  should  not 
have  been,  and  that  the  proof  is  completed  by  the 
perfectly  aseptic  course  of  the  wound  subsequently. 

Be  it  observed,  then,  that  not  merely  did  Pasteur, 
creating  bacteriology,  permit  Lister  to  create  mod- 
ern surgery  and  the  revolution  of  forty  years  ago, 
but  that  to-day  bacteriology  works  hand  in  hand 
with  surgery  every  day.  This  close  association  be- 
tween the  practice  and  the  science  is  more  necessary 
than  ever  when  aseptic  surgery  is  practised,  and 
serves  even  further  to  refute  the  most  complete  of 
falsehoods  —  that  modern  surgery  has  abandoned 
the  principles  of  Lister. 

That  is  indeed  the  most  complete  of  falsehoods; 
and  so  clear  are  the  facts  that  even  an  unscrupulous 
advocate  could  afford  to  admit  to-day  what  must 
certainly  be  admitted  —  that  the  principles  of  sim- 
ple cleanliness,  which  served  Lawson  Tait  so  well, 
come  in  practice  exceedingly  near  the  best  aseptic 
surgery.  And  if  surgeons  nowadays  obtain  results 
which  far  transcend  his,  it  is  chiefly  because  their 
cleanliness  is  checked,  and  refined,  and  adapted  by 
the  bacteriological  knowledge  which  the  enemies  of 
Listerism  despise.  For  there  are  various  kinds  of 
cleanliness,  and  their  relations  and  differences  are 
all  illustrated  in  this  connexion. 


THE  DEVELOPMENT  127 

Ordinary  cleanliness  may  mean  absence  of  visible 
dirt,  or  little  more  than  that.  In  its  best  forms 
ordinary  cleanliness  is  practically  though  not  wholly 
identical  with  the  cleanliness  demanded  by  the  sur- 
geon. But  there  is  always  the  distinction  that  per- 
fect ordinary  cleanliness  does  not  necessarily  mean 
sterility  —  absence  of  living  microbes.  Thus, 
though  good  enough  for  all  ordinary  purposes,  and 
very  nearly  good  enough  for  surgical  purposes,  it  just 
falls  short  of  the  surgical  requirement.  Neverthe- 
less, it  is  a  precious  thing;  and  Pasteur  and  Lister 
have  told  us  why  it  is  a  precious  thing.  The  house- 
wife's dislike  of  dirt,  the  clean  person's  personal 
fastidiousness  —  which  have  long  been  laughed  at 
as  tending  towards  the  absurd  and  insane  —  are 
much  more  than  justified  by  the  revelations  of  bac- 
teriology: and  the  difference  between  life  and  death 
daily  depends  for  thousands  of  persons  upon  the  as- 
surance that  surgeons  and  their  assistants  shall  be  a 
thousand  times  more  fastidious  than  the  fussiest 
housewife  or  the  daintiest  belle,  being  not  only  far 
cleaner  than  anyone  else  now  existing,  but  far  cleaner 
than  any  human  beings  ever  have  been  in  the  past. 

Surgical  cleanliness  is  another  thing  than  ordinary 
cleanliness;  and  it  may  not  look  nearly  so  nice.  I 
have  seen  a  surgeon  proceed  to  an  operation  with 
what  appeared  a  thoroughly  black  thumb-nail  of  the 
original  Adamic  type.  But  he  was  careful  to  tell  us 
that  the  dirt  was  "  clean  dirt  " —  being  in  fact  ster- 
ilised cobbler's  wax.  "  Clean  dirt  "  is  a  phrase  full 
of  meaning  for  the  hygienist  and  the  surgeon,  for 
surgical  cleanliness  is  simply  absence  of  living  mi- 


128  SURGERY  AND  SOCIETY 

crobes,  no  more  and  no  less;  and  to  realise  that  the 
only  objection  to  dirt  is  the  life  it  contains  is  to  ap- 
preciate to  the  full  the  profound  and  ever  necessary 
philosophy  of  the  saying  that  dirt  is  only  matter  in 
the  wrong  place.  It  may  be  added  that  hygienic 
training  gives  one,  and  will  in  due  course  give  us  all 
—  for  hygienic  training  will  be  part  of  general  edu- 
cation before  very  long,  and  I  hope  to  live  to  see  and 
hasten  the  day  when  no  educated  person  will  buy 
such  a  book  as  this,  any  more  than  a  copy  of  the 
alphabet  —  a  trick  of  distinguishing  the  dangerous 
from  the  innocent  forms  of  dirt,  quite  otherwise 
than  most  of  us  judge  of  dirt,  by  its  colour  contrast 
with  its  surroundings,  and  by  nothing  else.  Thus, 
to  take  the  first  instance  that  occurs,  one  may  wash 
one's  finger,  accidentally  stained  with  a  drop  spilt 
from  a  cup  of  chocolate,  by  licking  it:  but  for  the 
surgeon  this  would  be  to  substitute,  superficially,  for 
surgical  cleanliness  (as  the  chocolate  has  been 
boiled) surgical  dirt  (as  his  saliva  has  not).  It  need 
scarcely  be  said  that  the  operator  must  not  touch 
his  face  nor  adjust  his  eye-glasses,  much  less  allow 
his  fingers  to  come  into  contact  with  the  abundant 
"  flora  "  of  his  mouth. 

And,  thirdly,  there  is  chemical  cleanliness,  which 
is  neither  ordinary  cleanliness,  nor  surgical  cleanli- 
ness, but  is  related  to  both.  For  the  chemist  any- 
thing is  clean  which  contains  no  trace  of  any  chem- 
ical. Obviously,  if  one  is  examining  for  the 
presence  of  sodium  in  a  solution,  it  must  not  be  first 
poured  into  a  test-tube  which  contains  traces  of  any 
sodium  salt  —  such  as  are  practically  omnipresent. 


THE  DEVELOPMENT  129 

And  if  the  test-tube  does  not  satisfy  this  condition  it 
is  chemically  "  dirty,"  though  it  be  "  spotlessly 
clean  "  for  the  housewife,  and  perfectly  sterile  or 
clean  for  the  surgeon.  Thus  we  see  that  the  aim 
of  aseptic  surgery  is  to  leave  the  patient's  skin  not 
only  surgically  clean,  but  also  chemically  clean  so  far 
as  antiseptics  are  concerned. 

Of  the  results  of  aseptic  surgery  we  may  say  that 
they  are  the  results  of  surgery  at  the  present  day, 
for  aseptic  methods  are  practised  whenever  they  are 
applicable. 

Something  may  be  said,  however,  of  the  pros  and 
cons  in  the  controversy  between  the  extremists  and 
their  fellows,  as  to  the  advantages  of  extreme  rigour 
compared  with  a  more  generous  interpretation  of 
the  meaning  of  asepsis.  As  in  so  many  other  cases, 
we  find  that  some  surgeons  adhere  rigorously  to  the 
letter  of  the  law,  and  take  endless  trouble  to  prevent 
even  a  drop  of  boracic  acid  solution  from  reaching 
the  patient,  whereas  others  are  well  content  to  ob- 
serve the  spirit  of  the  law,  without  troubling  with 
so  much  exactness  as  that.  These  last  may  argue 
that  their  technique  is  slightly  safer,  being  less  haz- 
ardous in  its  dependence  upon  the  nice  and  punctil- 
ious observance  of  many  conditions,  by  operator  and 
assistant.  In  fact,  however,  the  best  modern  sur- 
geons, though  they  may  differ  quite  widely  in  va- 
rious details,  do  so  completely  satisfy  the  require- 
ments of  Listerism  that  we  who  do  not  operate  and 
are  not  called  upon  to  operate  neither  are  capable 
of  judging  nor  are  required  to. 

But  the  controversy  intimately  concerns  us  when 


130  SURGERY  AND  SOCIETY 

we  transfer  it  from  the  sphere  of  surgery  to  the 
question  of  the  preservation  of  food.  To  that  most 
important  question  a  few  pages  must  be  devoted,  in 
statement  and  illustration  of  the  thesis  that  at  pres- 
ent we  are  in  the  stage  of  antiseptic  practice  in  this 
regard,  and  that  we  must  as  quickly  as  possible  pass 
on  the  stage  of  aseptic  practice,  which  has  advan- 
tages over  the  antiseptic  method,  in  this  universally 
important  question,  no  less  decided  than  in  the 
sphere  of  surgery.  The  increase  of  population,  and 
its  increasing  urbanisation,  yearly  add  more  urgency 
to  the  question  how  we  are  to  be  fed ;  for  the  needs 
of  the  citizen  of  London  or  New  York  are  those  of 
Homo  primigenius  in  all  fundamental  respects,  and 
every  extension,  in  time  and  space,  of  the  distance 
between  a  man's  mouth  and  the  place  where  what  he 
eats  is  found,  demands  more  knowledge  and  skill, 
if  this  tremendous  adventure  called  civilisation  is  not 
to  fail  in  our  own  day  as  it  has  invariably  done  in 
all  that  are  past. 

It  is,  indeed,  curious  to  consider  how  mankind 
persists  in  controverting  the  natural  order.  Woman 
is  the  head  of  the  Mammalia,  and  modern  woman, 
losing  the  most  unselfish  of  her  functions,  is  ceasing 
to  be  a  mammal.  And  man,  the  paragon  of  ani- 
mals, is  becoming  a  vegetable  in  a  fundamental 
respect.  For  one  of  the  major  distinctions  between 
the  animal  and  the  vegetable  is  that  the  latter,  living 
on  food  which  is  practically  everywhere,  is  fixed, 
whereas  the  animal,  unable  to  feed  on  the  common 
inorganic  constituents  of  air  and  soil,  and  requiring 
highly  specialised  and  relatively  scarce  forms  of  diet, 


THE  DEVELOPMENT  131 

is  essentially  locomotive.  Our  anatomy  and  physi- 
ology, our  bodies  and  our  senses,  our  functions  and 
our  appetites,  are  characteristically  those  of  a  crea- 
ture made  to  move  in  search  of  food  —  to  climb,  to 
root,  to  run,  to  catch.  But  civilisation  takes  no  note 
of  all  that,  and  the  citizen  no  longer  moves  in  search 
of  food.  He  has  become  a  sedentary  organism,  like 
a  plant;  and  his  food  has  to  be  brought  to  him,  as 
the  wind  brings  the  plant's  airy  diet.  But  this  in- 
volves a  whole  host  of  difficulties  for  which  there 
is  no  natural  provision,  civilisation  being  in  a  sense 
super-natural  as  man  is  certainly  the  super-animal. 
And  it  is  evident  that  this  question  of  the  preserva- 
tion and  carriage  of  our  food,  which  really  should 
be  consumed  in  a  fresh  state  as  and  where  we  find  it, 
is  one  of  the  very  first  which  must  be  satisfactorily 
answered  if  anything  at  all  like  the  modern  citizen 
is  to  persist. 

As  my  purpose  is  by  no  means  to  discuss  the  whole 
question,  but  rather  to  show  its  parallelism  with  the 
developments  of  surgery  and  its  dependence  on  the 
same  principles,  we  need  consider  only  one  food,  but 
as  that  food  is  milk,  and  as  septic  milk  (in  the  wid- 
est sense)  produces  the  commonest  of  surgical  dis- 
eases, namely,  surgical  tuberculosis,  we  shall  cer- 
tainly not  wander  too  far  from  our  main  subject. 

If  the  issue  between  the  aseptic  and  antiseptic 
methods  in  the  treatment  of  surgical  tuberculosis  is 
to  be  solved  in  the  only  perfectly  satisfactory  way, 
which  is  by  the  abolition  of  the  disease,  we  must 
properly  decide  the  issue  between  the  aseptic  and 
the  antiseptic  methods  in  the  treatment  of  milk  and 


132  SURGERY  AND  SOCIETY 

its  various  products,  such  as  cream  and  butter.  At 
present  we  are  in  the  crudest  antiseptic  stage  in  this 
respect.  The  milk  is  often  drawn  from  a  tuber- 
culous udder,  and  even  if  it  be  not,  it  is  certainly- 
contaminated  with  many  microbes,  some  of  them 
capable  of  doing  grave  injury,  long  before  it  has 
travelled  far  on  its  long  and  trying  journey,  with 
ever  so  many  changes,  from  the  cow  to  the  con- 
sumer. And  thus  the  only  way  of  getting  it  to  its 
journey's  end  with  any  practical  success  at  all  is  to 
treat  it  by  the  antiseptic  method,  as  vigorously  as  the 
law  may  allow.  Thus  formalin  and  salicylic  acid  and 
boracic  acid  and  other  drugs,  known  and  proved  poi- 
sons one  and  all,  are  regularly  added  to  the  milk,  and 
what  we  swallow  is  milk,  dead  microbes,  and  the 
poison  which  killed  them:  which  poison  then  pro- 
ceeds to  go  as  far  as  its  nature  and  amount  require 
in  the  direction  of  killing  us.  When  the  funda- 
mental problems  of  civilisation  come  under  serious 
review  by  persons  who  know  that  they  must  be 
solved,  and  who  are  thinking  not  of  the  next  election, 
but  of  the  next  generation,  the  whole  question  of  the 
employment  of  what  are  euphemistically  called  pre- 
servatives in  food  will  have  to  be  attended  to;  and 
we  shall  recognise  the  necessity  for  the  universal 
employment  of  the  aseptic  instead  of  the  antiseptic 
method.  This  will  be  in  wise  imitation  of  the  de- 
velopment of  surgery,  and  it  will  lead  us  a  long  way 
in  the  direction  of  a  better  thing  than  even  aseptic 
surgery,  and  that  is  the  disappearance  of  surgery  and 
surgeons  altogether. 

Here  and  there  are  the  beginnings  of  the  aseptic 


THE  DEVELOPMENT  133 

method  in  the  treatment  of  food;  and  they  will  rap- 
idly grow  as  we  come  to  realise  that  the  better  we 
treat  our  food  the  less  need  will  there  be  to  treat 
ourselves.  We  shall  soon  see  the  end  of  such  open 
imbecilities  as  the  exposure  of  bowls  of  milk  to  the 
air,  with  its  street-dust,  containing  what  street-dust 
contains  (which  may  be  swallowed  but  must  not  be 
said),  and  its  flies,  and  their  feet,  infected  by  the  ap- 
pointed food  of  flies  —  which,  also,  is  best  left  unde- 
fined. Somewhat  later,  such  other  reforms  as  de- 
mand neither  intelligence  nor  expense  of  the  re- 
formed will  be  effected  —  the  Daily  Mail,  which 
one  day  decided  to  make  us  all  eat  the  right  kind 
of  bread,  could  do  this  at  a  moment's  notice  —  and 
later  still  we  shall  begin  at  the  beginning,  and  insti- 
tute practically  aseptic  milking,  and  aseptic  transit, 
and  abolish  all  preservatives  from  our  milk  and  cream 
and  butter,  excepting  only  salt  (which  is  a  food), 
in  the  latter  case.  The  aseptic  method  will  in  due 
course  be  applied  to  the  whole  of  the  food  supply, 
not  of  course  to  the  letter,  but  in  essentials. 
Sometimes  we  shall  have  to  compromise  for  safety, 
just  as  the  surgeon  sometimes  must  compromise  be- 
tween the  antiseptic  and  aseptic  extremes;  but  in  any 
case  we  shall  effect  great  things  for  cities  and  citi- 
zens. Merely  by  way  of  a  concluding  hint,  it  may 
be  noted  that  no  one  is  now  able  to  say  to  what  ex- 
tent the  disabilities  of  citizens  and  their  children  de- 
pend upon  the  dosage  with  boracic  acid  which  is  their 
daily  and  lifelong  portion. 


CHAPTER  VIII 

LISTERISM  AND  MOTHERHOOD 

It  does  not  occur  to  us,  perhaps,  to  look  upon  child- 
birth as  the  equivalent  of  a  surgical  operation;  yet 
in  all  essentials  it  is  so,  and  there  are  great  and 
growing  reasons  why  we  should  look  upon  the  serv- 
ices of  Listerism  to  motherhood  as  transcending  all 
else.  As  the  years  pass,  the  scope  of  surgery,  now 
steadily  increasing,  will  still  more  rapidly  diminish, 
since  the  patients  will  not  be  forthcoming.  The  dis- 
appearance of  rickets  and  of  surgical  tuberculosis 
and  the  attainment  of  the  bio-chemical  control  of 
cancer,  to  take  no  other  instances,  will  progressively 
and  rapidly  diminish  the  importance  of  surgery  as  a 
servant  of  mankind:  here  we  celebrate  a  beneficent 
new  art  which  will  ere  long,  thank  Heaven,  be  almost 
a  lost  art.  But  the  necessities  of  birth  will  remain, 
nor  can  they  ever  be  circumvented  until,  perchance, 
science  abolishes  death.  We  shall  see  in  the  course 
of  this  chapter,  also,  that  a  very  important  and 
fertile  field  for  the  present  application  of  Listerian 
surgery  depends  upon  the  failure  to  apply  the  Lis- 
terian principle  to  childbirth,  from  which  failure 
flow  half  the  physical  miseries  of  womanhood  at  the 
present  time. 

There  are  at  least  three  special  reasons  why  it  is 
our  duty  to  insist  upon  the  importance  of  Listerism 

134 


LISTERISM  AND  MOTHERHOOD         135 

for  motherhood;  and  a  writer  whose  life  is  devoted 
first  and  foremost  to  the  divine  cause  of  Eugenics 
may  well  be  excused  if  he  insists  upon  those  reasons 
before  proceeding  to  review  the  history,  state  the 
lamentable  present  facts,  and  indicate  the  evident 
requirements,  of  this  great  subject. 

The  first  reason  is,  of  course,  that  truly  stupendous 
and  momentous  fact,  the  fall  in  the  birth-rate,  which 
is  proceeding  with  even  greater  acceleration,  and  will 
long  continue  to  proceed,  in  all  the  civilised  countries 
of  the  world;  if  for  the  moment  we  use  civilised  in 
the  sense  of  less  rather  than  more  illiterate,  other 
definitions  being,  of  course,  imaginable.  The  fall 
in  the  birth-rate  is  an  absolutely  inevitable  conse- 
quence of  what  has  been  called,  not  without  some 
show  of  justice,  the  greatest  discovery  of  the  nine- 
teenth century,  namely,  the  safe  and  efficient  control 
of  conception.  As  the  knowledge  has  spread,  the 
birth-rate  has  fallen,  and  it  will  have  at  least  as  much 
further  to  fall  as  the  information  in  question  has 
social  depth  to  penetrate  —  which  is  indeed  the  whole 
depth  of  the  social  stratum  from  which  the  greater 
part  of  the  present  birth-rate  is  derived. 

There  are  those  in  abundance  who  desire  to  "  mor- 
alise this  spectacle,''  and  evidently  the  moralist,  or 
the  student  of  morality,  has  a  notable  object  for  con- 
templation in  the  fact  that,  everywhere,  mankind 
desires  the  satisfaction  of  certain  instincts  out  of 
proportion  to  the  desire  for  their  natural  conse- 
quences. And  when  the  censor  turns  student  —  a 
humbler  and  more  arduous  part,  which  he  commonly 
thinks  beneath  him  —  he  may  profitably   compare 


i36  SURGERY  AND  SOCIETY 

the  relative  advantages,  in  moral  principle,  and  in 
social  result,  of  infanticide  and  the  control  of  parent- 
hood; of  a  mercilessly  brutal  struggle  for  existence 
and  its  preventive  amelioration;  in  a  word,  of  irre- 
sponsible and  responsible,  improvident,  animal,  and 
provident,  human  reproduction. 

These  studies  will  occupy  the  moralist  for  some 
time,  and  meanwhile  the  birth-rate  will  fall,  and 
births  will  become  proportionately  and  progressively 
more  precious  when  they  do  occur,  partly  on  account 
of  their  comparative  rarity,  and  partly  because,  some- 
day, the  Eugenic  ideal,  as  I  have  elsewhere  formu- 
lated it,  will  be  satisfied,  and  every  child  that  comes 
into  the  world  will  be  loved,  desired  and  cherished  in 
anticipation.  Already  the  slow  education  of  public 
opinion  is  beginning  to  take  effect.  Less  than  a  dec- 
ade ago,  the  general  comments  on  the  falling  birth- 
rate, when  new  figures  were  forthcoming,  took  the 
form  of  protest  and  indignation  and  surprise.  The 
figure  for  19 10  was,  of  course,  the  lowest  on  record, 
as  will  be  the  figures  for  191 1  and  19 12.  But  it  was 
noticeable  that  the  commentators  accepted  the  fact: 
and  the  time  is  at  hand  when  we  shall  realise  that, 
in  the  circumstances,  our  business  is  not  to  deplore 
the  evitable  but  to  remedy  what  can  be  remedied. 
That  is  no  inconsiderable  matter,  and  I  here  desire  to 
draw  special  attention  to  a  fact  which  will  one  day 
be  duly  appreciated,  and  the  sooner  the  better.  It 
is  that  the  application  of  Listerism  to  obstetrics,  not 
in  the  lectures  or  practice  of  leading  obstetricians, 
but  in  the  homes  of  the  people,  is  demanded  not  only 
in  the  interests  of  mothers  as  mothers  and  babies  as 


LISTERISM  AND  MOTHERHOOD         137 

babies,  but  also  in  relation  to  this  great  world-phe- 
nomenon, with  its  formidable  menace  to  the  destiny 
of  modern  civilisation. 

It  has  been  proved  by  Drs.  Newsholme  and  Stev- 
enson, and  by  the  Fabian  inquiry  which  we  owe  to 
Mr.  Sidney  Webb,  that  the  fall  in  the  birth-rate, 
whilst  partly  due,  as  such  a  fact  must  obviously  be 
due,  to  a  host  of  minor  influences,  is  essentially  due 
to  a  voluntary  decline  in  the  fertility  of  married  peo- 
ple. That  is  primarily  the  business  of  those  people, 
to  which  they  are  attending  and  will  attend:  after 
our  objurgations  as  before  them. 

But  it  must  be  realised  that,  supposing  this  new 
factor  were  obliterated,  the  birth-rate,  of  course 
much  higher,  would  even  so  be  by  no  means  as  high 
as  it  ought  to  be  —  whatever  that  phrase  exactly 
means  —  if  it  were  not  for  the  accidents  of  maternity. 
It  is  not  to  be  asserted  that  the  prevention  of  these 
accidents  would  now  compensate  wholly  for  the  fall 
in  the  birth-rate  due  to  the  voluntary  factor;  but  no 
one  who  is  acquainted  at  all  with  the  facts  of  ma- 
ternity among  the  poorer  classes  will  question  that 
the  prevention  of  these  accidents  would  mean  — 
and  will  mean  —  a  very  substantial  addition  to  the 
birth-rate  forthwith.  For  there  is  an  involuntary 
sterility  as  well  as  this,  practically  new,  voluntary 
sterility;  and  every  obstetrician  and  gynecologist 
knows  that  the  "  one-child  sterility "  which  is  its 
commonest  form,  is  usually  due  to  the  lack  of  due 
Listerian  obstetrics  when  the  first  child  was  born. 
What  applies  to  childbirth  applies  equally  —  and 
perhaps  more  frequently  —  to  miscarriage.     The  re- 


i38  SURGERY  AND  SOCIETY 

productive  career  of  the  patient  is  ended,  often  be- 
fore a  single  child  has  been  contributed  to  the  future, 
because  the  work  of  Pasteur  and  Lister  is  not  yet 
made  available.  To  this  let  us  add  the  number  of 
those  who  actually  die  after  childbirth,  owing  to  the 
same  reason,  and  we  shall  begin  to  realise  that  one 
of  the  most  evident  and  necessary  and  urgent  reme- 
dies for  an  inadequate  birth-rate  is  Listerism.  How 
many  of  my  readers  have  ever  so  much  as  fancied 
any  connexion  between  these  two  subjects?  Which 
of  the  bishops,  and  politicians,  and  publicists,  and 
censors-in-general,  who  daily  direct  and  harangue 
us,  which  of  the  "  statesmen  "  and  Imperialists  who 
scorn  social  reform  as  "  parish-pump  politics,"  has 
yet  so  much  as  discovered  Listerism  as  a  part-remedy 
for  the  falling  birth-rate,  to  say  nothing  of  any  at- 
tempts to  apply  it?  Yet  what  might  not  be  done 
if  for  the  flood  of  daily  rubbish  poured  forth  on 
this  subject  —  compared  with  which  questions  of  the 
11  Constitution  M  or  "  Church  and  State  "  are  mere 
parlour-games  —  we  were  to  substitute  a  little  action 
for  the  saving  of  the  nation's  mothers  from  dirt  in 
their  creative  hours ! 

Let  us  consider  now  the  second  of  the  special 
reasons  why  we  must  insist  upon  the  importance  of 
Listerism  for  motherhood  —  if  we  may  not  be  con- 
tent with  the  overwhelming  general  reason  that  Lis- 
terism serves  the  most  valuable  members  of  the  com- 
munity when  they  are  most  in  need  of  service. 

This  special  reason  is  that  we  must  do  what  we 
can  to  counteract  the  alarming  present  tendency  of 
the  women  most  desirable  for  marriage  and  mother- 


LISTERISM  AND  MOTHERHOOD         139 

hood  to  decline  these  functions  altogether,  or  if  not 
both  of  them,  at  any  rate  the  second.  The  time  is 
at  hand  when,  if  we  do  not  actually  require  to  tempt 
such  women  to  undertake  their  great  social  function, 
we  most  certainly  do  require  to  remove  such  objec- 
tions and  risks  as  may  be  removed.  If  we  want  for 
motherhood  the  very  finest  and  most  valuable 
women,  who  will  rightly  look  upon  themselves  as 
valuable,  we  must  do  what  may  be  done  to  remove 
the  risks  of  this  supreme  profession.  In  general, 
the  physically  risky  occupations  are  those  discharged 
by  the  least  valuable  and  most  easily  replaced  mem- 
bers of  the  community ;  but  motherhood  is  at  present 
in  the  remarkable  position  that,  in  risk  to  life  and 
health,  it  far  exceeds  coal-mining,  if  not  even  the 
trades  concerned  with  the  sale  of  alcohol,  whereas, 
unlike  these  occupations,  it  demands  and  has  a  sacred 
claim  upon  the  rarest,  highest,  and  most  valuable 
qualities  of  mind  and  body  that  a  human  being  may 
possess.  This  is,  in  some  sense,  an  anomaly,  which 
it  is  our  evident  duty  to  remove.  Listerism  trans- 
forms the  conditions  of  motherhood,  and  lowers  the 
attendant  risks  to  an  extent  which  is  beyond  calcu- 
lation. For  the  Eugenist  or  for  the  enlightened  pa- 
triot —  they  are  the  same  person  —  and  for  those 
who  desire  the  best  fruition  of  our  womanhood,  it 
is  now  and  henceforth  a  duty  to  make  motherhood 
a  safe  as  well  as  a  supremely  honourable  and  hon- 
oured profession.  In  later  pages  we  shall  see  how 
far  our  national  service  for  the  care  of  maternity 
yet  is  from  fulfilling  this  evidently  necessary  condi- 
tion. 


140  SURGERY  AND  SOCIETY 

To  the  third  of  the  special  reasons  for  the  appli- 
cation of  Listerism  to  maternity  a  few  words  must 
finally  be  devoted,  before  we  proceed  to  the  history 
of  our  subject.  It  is  that  maternity  makes  special 
and  increasingly  onerous  demands  upon  the  women 
of  the  higher  races.  In  general,  the  higher  races 
have  larger  heads,  not  only  in  maturity,  but  at  birth ; 
and  this  is  one  of  the  reasons  why  maternity  is  more 
exacting  for  the  civilised  woman  than  for  her  savage 
sister.  Doubtless  she  has  a  wider  pelvis,  but  even 
so  there  is  a  constant  struggle,  so  to  say,  between  the 
tendency  for  the  size  of  the  head  to  increase  and  the 
tendency  for  the  capacity  of  the  maternal  pelvis  to 
increase;  and  the  head,  with  all  that  it  may  be 
capable  of  and  all  that  depends  upon  it,  is  ever  at 
the  mercy  of  the  calibre  of  the  bony  ring  through 
which  it  makes  its  amazing  entry  into  the  world. 
Now  the  risk  of  infection  and  consequent  inflam- 
mation, during  or  shortly  after  childbirth,  is  directly 
proportional,  other  things  being  equal,  to  the  amount 
of  local  injury,  including  the  devitalisation  due  to 
mere  pressure,  done  by  the  child's  head  in  its  course, 
and  this  injury  will  evidently  be  greater  in  propor- 
tion to  the  size  of  the  child's  head.  Thus,  the  larger 
the  head,  the  greater  the  need  for  Listerism;  which 
is  familiar  doctrine  in  the  ears  of  every  doctor  or 
midwife  or  obstetric  nurse,  who  all  know  well  that 
the  birth  of  a  boy,  his  head  being  bigger,  involves 
greater  risk  and  needs  more  care,  than  the  birth  of 
a  girl.  All  mothers  require  Listerism,  but  the 
mothers  of  boys,  and  especially  of  boys  born  in  a 
first  confinement,  require  it  pre-eminently.     Let. us 


LISTERISM  AND  MOTHERHOOD         141 

now  see  what  Listerism  has  already  done  for  mother- 
hood, and  we  shall  begin  to  realise  what  it  will  do. 

But  first  there  is  a  possible  criticism  of  which  it 
is  difficult  to  write  without  some  impatience.  This 
is  the  very  familiar  and,  at  first  sight  (which  is  no 
sight)  plausible,  objection  to  all  improvements  in 
sanitation  or  hygiene,  in  diet  or  medicine,  that  our 
ancestors  "  got  along  very  well  without  all  these 
new-fangled  scientific  devices."  It  is  somewhat  sim- 
ilar to  the  argument  that  our  grandfathers  and  grand- 
mothers —  the  critics  are  doubtless  speaking  for 
themselves  —  drank  freely  and  were  very  hearty  and 
successful  people;  then  why  not  we? 

And  the  reply  to  it  is  the  same.  We  have  half 
the  death-rate  or  less,  that  our  ancestors  "  enjoyed," 
and  are  in  our  prime  at  ages  which  they  never  at- 
tained at  all,  and  the  less  we  drink  the  longer  we  live. 
So  also  with  the  application  of  Listerism  to  mother- 
hood. 

The  argument  of  the  objector  gains  immensely  in 
a  priori  force  in  this  case,  since  motherhood  is  un- 
questionably a  natural  function,  and,  as  such,  should 
stand  in  no  need  of  artificial  assistance.  But  we  for- 
get that  cities  and  houses  are  not  "  natural  "  in  that 
sense  of  the  word,  and  that  we  ask  the  mother  to 
perform  her  "  natural "  function  under  intensely 
"  unnatural  "  conditions,  involving  risks  to  which  the 
primitive  mothers  of  our  species  were  doubtless  not 
exposed  at  all:  so  to  say,  there  were  no  cesspools  in 
the  Garden  of  Eden. 

Such  is  one  answer,  and  a  very  important  one, 
but  it  is  not  the  answer  which  was  first  in  my  mind 


142  SURGERY  AND  SOCIETY 

to  set  down.  That  is  the  answer  provided  by  the 
maternal  death-rate  in  the  pre-Listerian  days  when 
they  "  got  along  very  well  without  your  boasted 
science."  They  did  not  get  along  very  well.  On 
the  contrary,  they  fared  very  ill.  We  are  the  chil- 
dren of  the  survivors;  just  as  we  are  those  who  es- 
caped the  infant  mortality  which  is  none  the  less  a 
real  and  immense  fact.  The  argument  against  the 
new-fangled  notions,  which  is  supposed  to  be  de- 
rived from  the  days  before  their  dawn,  is  not  merely 
a  bad  argument  for  that  side ;  it  is  the  best  argument 
for  our  side.  And  sometimes  one  may  be  excused 
for  wishing  that  it  were  possible  to  transport  these 
arm-chair  critics  of  science  for  even  one  hour  into 
those  "  good  old  days  "  of  which  they  write,  and  to 
which  one  can  only  apply  the  admirable  pun  of  Dis- 
raeli —  they  were  the  palmy  days  that  had  no  date. 
Let  us  see,  then,  what  were  the  facts  of  motherhood 
in  pre-Listerian  times. 

Here  we  must  at  once  distinguish  sharply  between 
two  fundamentally  different  things,  childbirth  un- 
interfered  with,  and  childbirth  as  it  occurs  under  the 
care  of  midwife,  nurse  or  doctor.  Natural  child- 
birth, as  we  may  observe  it  amongst  primitive  peo- 
ples —  though  the  midwife  is  often  to  be  found  there, 
too  —  or  amongst  the  lower  animals,  is  very  largely 
protected  from  infection.  Nothing  occurs  to  in- 
troduce it,  and  the  trend  of  events  is  towards  ex- 
pulsion rather  than  introduction.  The  patient  is  not 
confined  in  infected  surroundings,  she  is  not  in  the 
same  ward  with  other  patients  who  are  infected  and, 
having  no  attendant   at   all,   she*  runs   no  risk  of 


LISTERISM  AND  MOTHERHOOD         143 

danger  from  doctor,  midwife,  student,  or  nurse,  who 
may  have  come  straight  from  opening  an  abscess,  or 
from  the  post-mortem  room,  or  the  dissecting-rooms. 
'And  further,  anyone  who  will  consider  the  anatomy 
and  physiology  of  the  function  of  childbirth  from 
the  point  of  view  of  Listerism  will  perceive  that 
the  natural  obstacles  to  and  provision  against  infec- 
tion are  various,  efficient  and  almost  insuperable. 
It  is  only  with  human  interference  that  the  risk 
begins. 

Why,  then,  interfere?  some  may  say.  The  an- 
swer is  that,  whatever  may  be  the  case  of  the  savage 
woman,  civilised  woman  and  her  child  are  the  better 
for  proper  attention  at  this  time.  The  confinement, 
indeed,  should  be  the  most  important  date,  merely, 
in  the  course  of  medical  supervision  extending  from 
many  months  before  it  to  some  time  after.  It  would 
merely  blur  the  main  outlines  of  this  chapter  if  we 
were  to  set  forth,  in  adequate  detail,  the  reasons  why 
obstetric  science  is  called  for,  notwithstanding  that 
childbirth  is  a  normal  function.  It  must  suffice 
merely  to  say  that  never  was  normal  function  so  near 
the  pathological  as  this  is. 

Let  it  be  assumed,  then,  that  the  obstetrician, 
whether  doctor  or  midwife,  is  required  in  greater  or 
less  degree.  With  him  or  her  there  enters  not 
merely  a  safeguard  or  possible  saviour  of  mother 
or  child  or  both,  in  many  common  circumstances,  but 
also  a  most  substantial  risk.  Or  rather,  one  should 
say,  there  did  enter,  and  may  enter,  a  most  substan- 
tial risk;  but  Pasteur  and  Lister  have  revealed  the 
facts,  and  so  far  from  this  special  risk  now  attaching 


144  SURGERY  AND  SOCIETY 

to  good  obstetrics,  it  lessens  the  naturally  very  slight 
risk  of  infection. 

It  was  the  very  profession  of  the  attendant  that 
constituted  the  bulk  of  the  danger;  it  was  the  very 
fact  that  the  lying-in  hospital  was  a  lying-in  hospital 
that  made  it  dangerous  for  the  lying-in  woman. 
One  does  not  take  a  sufferer  from,  shall  we  say,  vari- 
cose veins,  and  treat  him  in  a  small-pox  hospital. 
But  we  did  take  women  who  were  not  suffering  from 
surgical  inflammation,  and  put  them,  at  the  very  time 
when  they  were  to  undergo  a  wounding  (a  natural 
wounding,  but  that  made  no  difference)  beside  pa- 
tients who  were  suffering  from  this  terrible  infection. 
And  thus,  if  things  were  risky  In  ordinary  practice 
in  the  patients'  homes,  and  if  there  was  an  obvious 
danger  in  the  carriage  of  microbes  to  the  suscepti- 
ble, the  risk  was  vastly  greater  in  maternity  hospitals. 

It  could  often  be  shown  that,  with  strict  and  literal 
accuracy,  these  hospitals  were  more  deadly  than  the 
battlefield:  the  proportion  of  those  killed  in  giving 
life  was  higher  than  amongst  those  who  went  forth  | 
to  take  it.     It  was  said  in  Paris  in  1866  that  "  women 
of  the  lower  classes  looked  upon  the  Maternite  as  the  L 
vestibule  of  death. "     And  well  they  might,  for  in  I 
January    and    February    of   that   year    there    were  ; 
twenty-eight  deaths  out  of  one  hundred  and  three 
cases  —  one   mother   in   less  than   every    four  was 
killed.     Mere  decimation  is  nothing  to  it. 

All  honour  to  the  few  who  fought  against  such 
things.  Amongst  them  was  Oliver  Wendell  Holmes, 
himself  a  physician  and  anatomist,  who  protested 
against  the  appalling  mortality  of  childbirth  in  his 


LISTERISM  AND  MOTHERHOOD         145 

own  time  and  place ;  and  earned  the  customary  meas- 
ure of  gratitude  awarded  by  their  professional  con- 
temporaries to  medical  reformers. 

Far  worse,  far  more  tragic  and  far  more  instruct- 
ive, is  the  case  of  Ignaz  Semmelweis,  the  tragedy  of 
whose  life,  as  Mr.  Stephen  Paget  has  remarked,  can- 
not be  told  too  often.  It  teaches  the  history  of  this 
subject,  it  illustrates  the  everlasting  conflict  between 
authority  and  innovation,  and  by  its  pathetic  end, 
scarcely  more  than  a  decade  before  Pasteur's  great 
detection  of  the  mothers'  microbic  enemy,  it  en- 
forces afresh  the  truth  that  he  alone  discovers  who 
proves. 

Semmelweis  began  to  work  in  the  maternity  de- 
partment of  the  general  hospital  in  Vienna  in  1846. 
He  was  only  twenty-three,  and  in  less  than  two  dec- 
ades he  had  died  insane.  There  is  nothing  more 
poignant  in  the  history  of  medicine  than  the  record 
of  those  years. 

Things  were  very  bad  when  Semmelweis  was  ap- 
pointed, and  had  been  for  many  years.  The  mor- 
tality amongst  the  mothers  from  child-bed  or  puer- 
peral fever  ranged  from  5  to  16  per  cent.  But  it 
had  a  special  distribution.  Here  I  cannot  do  better 
than  quote  three  paragraphs  from  Mr.  Stephen 
Paget's  admirable  account:  — 

"  There  were  two  sets  of  wards  in  the  maternity 
department.  The  one  may  be  called  Clinique  A, 
and  the  other  Clinique  B.  For  many  years  the 
mortality  had  been  the  same  in  each.  In  1841  a 
change  was  made :  Clinique  A  was  .assigned  to  the 


146  surgery  and  society 

teaching  of  students,  and  Clinique  B  to  the  teach- 
ing of  midwives:  and  so  soon  as  this  change  had 
been  made,  the  mortality  in  Clinique  B  became 
less,  but  the  mortality  in  Clinique  A  did  not.  Com- 
missions of  inquiry  were  held  and  in  vain.  It 
was  suggested  that  the  foreign  students  were  some- 
how to  blame,  nobody  knew  why;  and  many  of 
them  were  sent  away.  Still  the  deaths  went  on. 
Women  admitted  to  Clinique  A  would  go  down  on 
their  knees  and  pray  to  be  allowed  to  go  home; 
almost  every  day  the  bell  was  heard  ringing  in  the 
wards,  for  the  administration  of  the  Sacrament  to 
a  dying  woman.  People  talked  about  atmospheric 
influences,  and  overcrowding  and  the  tainted  air 
of  old  wards,  and  the  power  of  the  mind  over  the 
body:  and  Semmelweis  set  to  work. 

"  He  observed  that  cases  of  protracted  labour 
in  Clinique  A  died,  almost  all  of  them ;  but  not  in 
Clinique  B.  He  observed,  also,  that  cases  of  pre- 
mature labour,  nearly  all  of  them,  did  well,  which- 
ever Clinique  they  were  in;  so  did  those  women 
who  were  delivered  before  they  came  to  the  hos- 
pital, and  were  admitted  after  delivery.  He  ob- 
served that  a  row  of  patients,  lying  side  by  side, 
would  all  be  attacked  at  once  in  Clinique  A; 
which  never  happened  in  Clinique  B.  He  tried 
everything:  he  altered  the  details  of  treatment; 
he  used  various  subterfuges  to  prevent  one  of  the 
professors  from  examining  serious  cases;  he  en- 
forced this  or  that  rule  in  Clinique  A,  because  it 
was  the  custom  in  Clinique  B;  he  slaved  away 
at  the  notes  of  the  cases  —  and  at  last  the  truth 


LISTERISM  AND  MOTHERHOOD         147 

came  to  him,  by  the  death  of  one  of  his  friends 
from  a  dissection-wound.  He  says,  *  My  friend's 
fatal  symptoms  unveiled  to  my  mind  an  identity 
with  those  which  I  had  so  often  noticed  at  the 
death-beds  of  puerperal  cases.'  He  saw  now  that 
the  students,  coming  straight  from  the  dissecting- 
rooms,  had  infected  the  patients  during  examina- 
tion. 

"  In  May,  1847,  he  gave  orders  that  every  stu- 
dent, before  examining,  should  thoroughly  disin- 
fect his  hands.  But,  though  he  had  reckoned  with 
dissecting-room  poisons,  he  had  forgotten  to 
reckon  with  other  sources  of  infection.  In  Octo- 
ber of  that  year,  a  woman  was  admitted  who  had 
malignant  disease;  of  twelve  women  examined 
after  her,  eleven  got  puerperal  fever,  and  died. 
In  November,  a  woman  was  admitted  who  had  a 
suppurating  knee-joint,  and  eight  women  were  in- 
fected from  her  and  died.  Therefore  Semmel- 
weis  said,  '  Not  only  can  the  particles  from  dead 
bodies  generate  puerperal  fever,  but  any  decom- 
posed material  from  the  living  body  can  also  gen- 
erate it,  and  so  can  air  contaminated  by  such  mate- 
rials.' Henceforth  he  isolated  all  infected  cases, 
he  enforced  the  strict  use  of  disinfectants :  and  the 
mortality  in  Clinique  A,  which  in  May,  1847,  had 
stood  at  12.24  Per  cent,  fell  in  December  to  3.04, 
and  in  1848  was  1.27." 

The  rest  is  tragedy.  Semmelweis  was  opposed  by 
his  chief  and,  despite  a  good  beginning  to  its  fame, 
his  work  was  discredited,  and  the  University  authori- 


148  SURGERY  AND  SOCIETY 

ties  turned  him  out  of  his  post,  the  hospital  and 
Vienna.  Year  after  year  his  enemies  gained  in 
power;  his  work  could  not  be  verified  by  proof;  and 
in  1865,  after  a  few  last  weeks  in  an  asylum  at 
Vienna,  he  died. 

And  after  his  death  followed  those  of  countless 
women  all  over  the  world  whom  he  had  just  failed 
to  save.  We  have  seen  the  figures  from  Paris  in  the 
sixties,  and  they  are  typical.  Not  until  1877  did  the 
Listerian  method  come  into  use,  and  in  the  following 
year  Pasteur  showed  that  the  too  familiar  strepto- 
coccus —  the  round-celled  microbe  which  grows  in 
adherent  chains  —  is  the  cause  of  puerperal  infection. 
"  One  day,"  says  Roux,  "  during  a  discussion  on 
puerperal  fever  at  the  Academy  of  Medicine,  one  of 
his  most  renowned  colleagues  was  eloquently  dis- 
coursing upon  the  causes  of  epidemics  in  maternities. 
Pasteur  interrupted  from  his  place  — '  What  causes 
an  epidemic  is  none  of  all  that:  it  is  the  doctor  and 
his  assistants  who  carry  the  microbe  from  an  ill 
woman  to  a  healthy  one.'  And  when  the  orator  re- 
plied that  he  much  feared  one  would  never  find  this 
microbe,  Pasteur  went  to  the  blackboard,  and  drew 
the  organism  with  its  row  of  grains,  saying,  *  Tenez, 
void  sa  figure/  " 

A  generation  has  passed  since  that  day,  and  there 
are  no  more  epidemics  in  maternities.  As  a  medical 
student  and  as  resident  physician  to  the  Edinburgh 
Maternity  Hospital  I  had  a  fair  share,  even  during 
my  brief  days  of  medical  practice,  of  obstetric  ob- 
servation, comprising  some  of  the  worst  slums,  and 
perhaps  the  most  famous  slum  population   in  the 


LISTERISM  AND  MOTHERHOOD         149 

Empire  —  that  which  started,  after  the  Boer  War, 
our  interest  in  the  national  physique.  But  I  have 
never  seen  a  case  of  puerperal  septicaemia,  much  less 
a  death  from  the  disease.  Like  pyaemia,  it  is  be- 
come a  name  to  those  whose  observation  has  been 
confined  to  obstetrics  of  the  modern  school. 

In  this  case  also,  as  we  might  expect,  the  evolution 
of  practice  has  followed  that  of  operative  surgery. 
In  1877  carbolic  acid  reached  the  Paris  Maternity 
Hospital,  but  we  may  be  very  sure  that  much  less 
is  used  there  now  than  then  —  though  it  is  more 
valuable  than  ever.  Antiseptic  midwifery  was  the 
first  stage.  Semmelweis  had  practised  it  in  the 
forties,  but  his  arguments  were  empirical  only,  and 
could  not  prevail  against  the  prejudice,  self-interest 
and  conservatism  of  the  day.  The  identification  of 
the  fatal  microbe,  and  the  study  of  its  habits  and 
modes  of  conveyance,  together  with  the  success  of 
antiseptic  surgery,  led  obstetricians  to  employ  the 
methods  of  primitive  Listerism,  with  immediate  and 
striking  success.  Powerful  antiseptic  solutions  were 
in  demand,  of  carbolic  acid  and  perchloride  of  mer- 
cury, and  the  copious  douching  in  favour  for  other 
purposes  could  readily  be  adapted  to  the  antiseptic 
idea. 

And  now  is  the  age  of  aseptic  midwifery.  Nor- 
mally the  attendant  has  to  deal  with  what,  from  the 
surgical  point  of  view,  is  the  exact  parallel  of  an 
operation  upon  unbroken  skin  —  say  for  the  straight- 
ening of  a  rickety  limb.  Nature  is  the  surgeon,  and 
she  makes  her  aseptic  wound  for  her  purpose,  as 
the  surgeon  would  make  a  wound  with  the  knife  for 


150  SURGERY  AND  SOCIETY 

his,  and  in  either  case,  if  infection  occurs,  the  opera- 
tor put  it  there.  There  are  imaginable  and  even 
possible  exceptions,  but  they  may  be  wholly  ignored. 
If,  then,  the  patient  be  uninfected  in  the  first  place, 
the  use  of  antiseptics  will  tend  to  injure  her  living 
tissues,  and  will  find  no  enemies  of  hers  to  kill.  They 
must  therefore  be  used  only  if  and  when  there  is 
reason  to  suppose  that  infection  has  been  or  may 
have  been  introduced.  Otherwise  only  sterile  lo- 
tions —  of  which  boiled  water  or  "  physiological  salt 
solution  "  is  the  type  —  must  be  permitted  to  come  in 
contact  with  the  patient's  tissues,  or  at  any  rate  those 
tissues  of  which  the  vital  task  of  healing  is  about 
to  be  required.  Under  these  conditions  we  may  al- 
most achieve  the  remarkable  feat  of  reproducing, 
rivalling,  if  not  surpassing,  in  the  modern  city,  the 
simplicity,  safety  and  ease  with  which  we  may  doubt- 
less credit  primitive  natural  childbirth.  The  pa- 
tient's temperature  does  not  rise,  her  pulse  is  even 
slower  than  usual,  everything  takes  a  rapid  uninter- 
rupted course,  not  towards  health,  for  health  has  in- 
deed never  been  departed  from,  but  towards  repair. 
There  are  no  disastrous  sequela  of  any  kind.  The 
mother  is  normal  again  in  every  way,  and  her  re- 
productive career  is  not  interfered  with  by  any  dis- 
placement, or  relic,  or  enlargement  or  congestion. 
The  absence  of  fever,  and  of  the  poisoning  of  which 
the  fever  is  merely  a  symptom,  greatly  reduces  the 
likelihood  that  the  chemical  or  bio-chemical  strain  of 
pregnancy  and  childbirth  will  lead  to  mental  disturb- 
ance. Very  few  members  of  the  general  public  are 
at  all  aware  how  common  and  how  important  is 


LISTERISM  AND  MOTHERHOOD         151 

puerperal  insanity  —  a  major  factor  in  the  statistics 
of  mental  alienation.  This  is  doubtless  of  complex 
causation,  like  all  other  vital  phenomena,  but  there  is 
no  doubt  whatever  that,  other  things  —  such  as 
heredity  —  being  equal,  the  occurrence  of  puerperal 
infection  will  often  cause  puerperal  insanity,  with  all 
that  that  may  mean,  including  possibly  infanticide 
and  suicide. 

There  is  a  branch  of  medico-surgical  practice 
which  is  concerned  with  gynecology  or  the  "  diseases 
of  women."  The  term  is  very  general,  and  com- 
prises much.  It  is  only  in  very  small  proportion, 
however,  that  the  unmarried  woman  requires  to  con- 
sult the  gynecologist.  The  great  proportion  of  all 
gynecological  cases,  those  which  are  treated  in  hos- 
pitals for  women  or  the  special  wards  of  general 
hospitals,  those  which  are  seen  in  private  by  the 
specialist,  those  which  are  dealt  with  by  the  general 
practitioner  of  all  kinds,  including  even  the  "  six- 
penny "  and  fourpenny  "  doctor,  and  those  which 
receive  neither  treatment  nor  the  pretence  of  it,  are 
due  to  two  causes.  Of  these,  one  is  infection  by 
a  particular  coccus,  in  general  form  not  unlike  the 
almost  omnipresent  cocci  of  original  surgical  inflam- 
mation, but  nevertheless  distinct  and  known  as  the 
gonococcus.  This  is  an  evil  which  does  not  concern 
us  here,  though  when  it  is  put  an  end  to,  it  will  be 
because  the  principles  of  Pasteur  and  Lister  have 
been  applied.  The  other  cause  is  imperfect  atten- 
tion at  childbirth,  commonly  if  not  invariably  in- 
volving a  greater  or  less  degree  of  infection  by  mi- 
crobes.    These  unfortunate  patients  pay  a  long  and 


152  SURGERY  AND  SOCIETY 

lamentable  price  for  their  motherhood  —  not  always 
even  actual  motherhood,  but  often  abortive  —  and 
this  injury  to  so  many  individuals,  together  with  its 
enormous  cost  to  the  philanthropic,  has  to  be  reck- 
oned, besides  the  associated  injury  to  the  birth-rate, 
if  we  are  to  appraise  the  consequences  of  the  failure 
to  apply  Listerism  to  a  nation's  midwifery. 

u  The  obstetrician  should  be  the  cleanest  man  on 
God's  earth,"  used  to  say  one  of  my  old  teachers, 
Sir  Halliday  Croom,  now  Professor  of  Midwifery  in 
the  University  of  Edinburgh.  And  so  he  should. 
Let  us  see  what  the  facts  are  and  what  they  should 
be.  It  may  be  permitted  to  recount  my  own  experi- 
ence, which  is  both  representative  and  comprehen- 
sive. I  undertook  the  practice  of  a  friend  for  a 
short  time  in  a  pit-village  in  Northumberland;  saw 
the  maternity  conditions  for  some  time  in  ordinary 
middle-class  practice,  for  three  months  in  Hungate, 
the  worst  slum  quarter  of  York,  for  as  many  years 
in  the  Old  Town  of  Edinburgh,  including  that  un- 
utterably degenerate  and  indescribable  slum  popu- 
lation which  Professor  Karl  Pearson  unluckily  took 
to  be  a  representative  sample  of  the  working-class 
population  when  he  desired  to  study  the  influence  of 
parental  alcoholism ;  and  in  the  Edinburgh  Maternity 
Hospital. 

Here,  of  course,  was  the  never-to-be-forgotten 
contrast,  the  memory  of  which  dictates  these  pages, 
between  the  worst  imaginable  conditions  for  ma- 
ternity, vastly  worse  from  the  Listerian  point  of  view 
than  anything  to  be  found  amongst  savages  or  ani- 
mals—  and  the  best  imaginable  conditions,  such  as 


LISTERISM  AND  MOTHERHOOD         153 

philanthropy,  science,  and  the  desire  to  uphold  the 
reputation  of  the  school  where  Sir  James  Simpson  and 
Lord  Lister  taught,  could  provide.  Sometimes  one 
attended  a  labour  outside,  sometimes  inside:  often 
the  merest  chance  decided  whether  any  particular 
mother  should  face  her  crisis  within  or  without,  if 
it  was  not  the  case,  indeed,  that  the  married  mothers 
usually  preferred  to  stay  at  home,  in  what  Mammon 
provided,  whereas  the  unmarried  mothers  more  often 
accepted  what  Love  and  Truth  provided.  Out  in 
the  night  of  Mammon  the  conditions  were  those  of 
slumdom  at  its  worst  —  say  in  the  "  Royal  mile" 
between  Holyrood  and  the  Castle.  Here  were  tiny 
apartments,  windows  grimy  and  incapable  of  open- 
ing, furniture  occupying  the  place  of  air,  dirt  omni- 
present, unwashed  and  reeking  neighbours,  useless, 
inquisitive,  morbidly  curious,  rich  with  all  manner  of 
infection,  consuming  the  hopelessly  inadequate  sup- 
ply of  unchanged  air,  and  substituting  for  it  the 
products  of  their  respiration,  skin  and  clothes.  The 
mother  like  unto  them,  and  previous  children  prom- 
ising the  same  characters  for  years  to  come.  The 
father  almost  certainly  intoxicated,  that  is  to  say, 
having  his  vital  functions  more  or  less  impaired  by  a 
present  dose  of  whiskey,  and  the  mother  freely  par- 
taking also, —  and  thus  contriving  to  dose  the  child 
before  ever  it  opened  its  eyes  on  the  darkness  and 
dirt.  (It  is  under  such  conditions  that  I  have  seen 
babies  born  drunk,  as  may  be  readily  understood.) 
But  whether  or  not  it  be  absorbing  alcohol  from  its 
mother's  blood,  the  unborn  child  is  at  least  clean  — 
the  one  clean  and  unstained  thing  in  all  that  filth 


154  SURGERY  AND  SOCIETY 

and  degradation.  To  its  aid  there  would  arrive  the 
doctor  and  the  two  nurses  —  one  for  the  mother  and 
one  for  the  baby  —  bringing  to  these  inhabitants  of 
"  modern  Athens,"  where  Simpson  and  Lister  taught, 
the  chloroform  for  the  mother  and  carbolic  acid  and 
alcohol  for  their  own  hands  which  represent,  surely, 
the  just  and  final  antithesis  to  the  forms  of  alcohol 
with  which  the  place  already  over-abounds.  Add 
only  the  picture  of  a  violent  knocking  and  entry  at 
the  door,  just  when  the  doctor  is  receiving  the  child's 
head  into  his  hand,  and  into  the  world,  and  the 
necessity  for  high  words  and  blows,  because  the 
whiskey-bottle  has  been  left  in  the  room.  First  re- 
ceive the  child's  head  into  your  hands,  then  fight  its 
drunken  father,  then  be  sure  to  cleanse  them  of  the 
filth  before  they  go  near  the  mother, —  and  then  for- 
get it  while  you  live,  if  you  can. 

But  that  is  not  the  worst,  for  it  is  incalculably 
ameliorated  by  the  entry  of  the  emissaries  from  the 
Maternity  Hospital.  What  of  the  rooms  where  no 
such  emissaries  enter,  where  Mrs.  Gamp  still  pre- 
vails, applying  as  much  alcohol  to  her  stomach  as  the 
Listerian  obstetric  nurse  applies  to  her  skin?  The 
truth  is  that,  in  Great  Britain,  very  much  less  than 
half  of  all  the  maternity  cases  yet  received  proper 
care,  or  rather,  one  should  say,  the  chance  of  proper 
care.  The  rest  certainly  do  not  receive  it,  and 
though  the  resources  of  Nature,  even  under  the  most 
unnatural  conditions,  are  marvellous,  large  numbers 
of  these  mothers  suffer  in  consequence.  Some  thou- 
sands die  every  year  from  puerperal  fever,  due  to 
infection  by  the  hands  which  have  come  to  help 


LISTERISM  AND  MOTHERHOOD         155 

them,  and  a  vastly  larger  number  are  left  with  ail- 
ments which  in  many  cases  are  lifelong. 

But  a  tiny  fraction  of  the  mothers  who  are  ex- 
posed to  such  conditions  as  I  have  attempted  to  de- 
scribe are  fortunate  enough  to  find  their  way  into  a 
modern  Maternity  Hospital  of  the  first  rank.  We 
have  seen  what  maternity  hospitals  were,  and  why. 
But  nowadays  they  are  practically  surgical  hospitals 
where  every  case  is  a  major  operation  and  where  the 
conditions  must  be  appropriately  complete  in  their 
Listerian  provision.  The  delivery-room  is  simply 
a  surgical  theatre  of  the  first-class  as  regards  air, 
light,  rounded  angles,  tiled  walls,  and  the  rest.  No- 
where in  the  world,  nor  in  any  other  sphere  of  ex- 
istence, will  you  find  a  greater  contrast  than  that 
between  the  room  in  the  slum  and  the  room  in  the 
hospital.  Save  for  the  presence  of  walls,  floor  and 
roof  in  both  cases  —  and  these  are  as  different  as  can 
be  —  the  two  apartments  are  at  the  absolute  ex- 
tremes, every  feature  of  the  one  directed  towards 
death,  every  feature  of  the  other  calculated  for  and 
directed  towards  life.  In  order  to  point  the  contrast 
as  it  really  is,  one  would  have  to  describe  in  detail 
a  modern  surgical  theatre,  the  precautions  as  to  those 
who  may  enter  it,  the  kind  of  provision  for  specta- 
tors, the  washing  of  the  air  before  admission  and  so 
forth.  It  is  all  quite  different  from  a  slum,  but  we 
must  wait  for  a  later  chapter  to  describe  it. 

In  this  theatre  not  merely  normal  confinements  are 
superintended  —  with  the  irreducible  minimum  of 
examination  and  interference,  all  rigorously  aseptic 
—  but  also  the  accidents  and  exceptions  of  maternity 


156  SURGERY  AND  SOCIETY 

are  dealt  with.  All  manner  of  operations  require 
to  be  performed,  possibly  at  very  brief  notice;  but 
the  conditions  for  them  are  present,  and  the  mother 
who  would  certainly  have  died  in  the  slum  may  be 
saved.  The  possible  quality  and  demands  of  ob- 
stetric surgery  may  be  indicated  by  the  case  of  what 
is  called  Caesarean  section,  where  the  child  is  born 
by  an  abdominal  section  —  the  only  means,  in  such 
cases,  whereby  the  terrible  dilemma  of  sacrificing 
either  mother  or  child  to  the  other,  may  be  avoided. 
This  truly  magnificent  achievement  is  in  our  own 
day  one  of  the  supreme  triumphs  of  Listerism,  and 
there  are  cases  where  the  surgeon  has  felt  himself 
justified  in  performing  the  operation  without  inter- 
fering with  the  possibility  of  future  occasions,  and 
where  one  and  the  same  mother  has  had  three  living 
children  brought  into  this  world  in  this  astounding 
fashion.  But  it  is  indeed  only  the  niceness  of  the 
layman's  palate  that  prevents  me  from  illustrating, 
in  many  almost  incredible  ways,  the  measure  of  what 
the  science  of  midwifery,  thanks  indispensably  to 
Lord  Lister,  can  now  perform  for  motherhood. 

Now  it  is  very  certain,  if  we  recall  the  contrast 
between  the  slum-bedroom  and  the  hospital  theatre, 
that  if  one  of  them  is  right  the  other  must  be  very 
wrong.  "  Yes,  no  doubt  it  is,"  some  will  say,  "  but 
we  must  take  the  world  as  we  find  it."  That  despic- 
able phrase  is  the  motto  of  the  impotent  and  the 
forgotten  in  all  ages:  let  us  see  to  it  that  neither 
we  as  individuals  nor  yet  the  civilisation  we  confess 
be  of  their  number.  And  let  us  realise,  sooner  rather 
than  later,  that  the  claims  of  Love,  advocated  per- 


LISTERISM  AND  MOTHERHOOD         157 

chance  not  only  by  the  wise,  but  also  by  the  maudlin- 
sentimental,  by  the  fanatic,  the  impractical,  the  revo- 
lutionary, are  in  our  own  day  reinforced  by  those 
of  Science  and  of  Patriotism  as  never  before.  It  is 
not  merely  that  every  mother  should  have  better 
conditions  rather  than  worse:  it  is  that,  as  Pasteur 
and  Lister  have  proved  to  us,  the  difference  between 
conditions  is  not  one  of  better  and  worse,  but  of 
right  and  wrong,  safe  and  fatal.  The  contrast  is  not 
merely  aesthetic  or  sentimental,  it  is  the  contrast  be- 
tween food  and  poison,  between  oxygen  and  car- 
bonic acid.  It  is  not  "  Providence  "  that  kills  the 
puerperal  mother,  it  is  simply  pus;  and  we  who 
know  where  pus  comes  from  and  how  it  may  be 
avoided,  are  responsible.  If  you  push  a  baby  over 
a  precipice  and  it  is  killed,  your  reference  to  the 
"  inscrutable  decree  of  Heaven  "  will  not  prevent 
your  arrest.  If  the  dirty  attendant  pushes  patho- 
genic microbes  into  the  maternal  passages  before, 
during  or  after  childbirth,  and  death  follows,  that  is 
the  work  not  of  Heaven  but  of  Earth ;  and  it  is  our 
immediate  business  to  see  to  it. 

"  That  it  may  please  thee  to  preserve  all  women 
labouring  of  child,  we  beseech  thee  to  hear  us,  good 
Lord."  Such  is  the  petition  which,  for  centuries,  has 
been  uttered  by  countless  voices  in  thousands  of 
churches.  The  numbers  of  those  who  echo  it  are 
falling  and  will  long  continue  to  fall :  but  as  we  cease 
to  petition  we  shall  work.  If  it  was  ever  true  that 
"  Laborare  est  orare"  it  is  a  thousand  times  truer 
now.  The  preservation  of  women  labouring  of  child 
depends  upon  the  practice  of  aseptic  midwifery,  far 


158  SURGERY  AND  SOCIETY 

beyond  all  other  things.  Men  are  ceasing  to  attend 
church ;  but  they  will  shortly  begin  to  pray  by  work- 
ing, and  then  Pasteur  and  Lister,  the  earthly  Provi- 
dence of  mothers,  will  preserve  all  women  labouring 
of  child,  as  they  were  never  preserved  before:  and 
even  the  women  who  still  join  in  that  beautiful  pe- 
tition are  learning,  after  church-time,  how  to  sterilise 
their  hands  and  thus  do  their  duty  of  preserving 
all  women  labouring  of  child.  It  is  many  years 
since  I  joined  in  the  response  to  that  lovely  Litany, 
of  which  a  phrase,  entirely  misunderstood  in  my 
boy's  mind,1  has  been  somehow  treasured  there,  and 
the  words  of  which  I  have  just  verified.  But  indeed 
it  is  amazing  to  read  those  petitions  now,  and  observe 
in  how  many  cases  we  are  doing  what  we  have  so 
long  prayed  for.  "  Young  children  "  are  interceded 
for,  and  I  think  of  our  infant  mortality  campaign 
and  the  simple,  persistent,  often  indignant  work 
which  has  taught  the  public,  promises  to  enlighten 
even  our  politicians,  and  has  already  saved  the  lives 
of  many  scores  of  infants  since  Edward  VII  came  to 
the  throne  and  this  one  campaign  of  the  "  Peace- 
maker "  was  inaugurated.  Verily  there  is  room  for 
reflection  on  the  centuries  during  which  that  prayer 
has  been  uttered,  and  the  death-rate  amongst  infants 
maintained  —  it  never  fell  during  the  sixty  years  of 
prayer  and  indolence  between  1840  and  1900  — 
whilst  one-third  of  the  whole  rate,  very  nearly,  was 
abolished  in  eight  years  when  we  left  the  churches 
for  creches,  and  prayer  for  work. 

The  time  has  come  for  deeds  in  the  matter  of 

1 1  thought  it  referred  to  mothers  tending  fractious  children. 


LISTERISM  AND  MOTHERHOOD         159 

this  petition,  too;  we  must  forthwith  "  preserve  all 
women  labouring  of  child."  It  is  the  logical  con- 
tinuation of  the  infant  mortality  campaign;  it  is  the 
clear  indication  afforded  by  the  falling  birth-rate; 
it  is  the  evident  demand  imposed  upon  us  by  the  fact 
that  we  now  know  what  the  authors  of  the  Book 
of  Common  Prayer  did  not  know;  it  is  an  evident 
field  for  philanthropy  and  it  is  fundamental  patri- 
otism. 

Elsewhere  I  have  advanced  the  recognition  of 
the  "  Rights  of  Mothers  "  as  a  social  principle  which 
is  fundamental  and  everlasting,  because  it  is  a  bio- 
logical principle  and  a  necessity  imposed  by  the  con- 
ditions under  which  our  species  is  reproduced.  The 
argument  of  that  demand  is  essentially  economic, 
and  does  not  here  concern  us,  but  a  reference  may 
be  made  to  the  underlying  principle  there  enunci- 
ated, by  way  of  introduction  to  the  demand  that  for 
every  mother  throughout  the  world  there  must  be 
provided,  at  the  least,  aseptic  midwifery  in  her  hour 
of  peril. 

Given  the  knowledge  we  now  possess,  the  repeti- 
tion of  the  Litany  in  our  churches  by  those  who  do 
nothing  for  the  nation's  motherhood  is  an  insult  to 
God  and  man.  When  those  beautiful  prayers  were 
written,  they  represented  the  sincere  knowledge  and 
belief  of  the  age.  The  Litany  does  not  pray  for 
their  obvious  and  inevitable  effects  to  be  averted 
from  the  acts  of  men;  it  seeks  to  mitigate  or  direct 
the  acts  of  God.  Year  by  year  the  boundary  be- 
tween man  and  God,  thus  understood,  is  moving: 
and   God  will   continue   to  be   banished    from   one 


i6o  SURGERY  AND  SOCIETY 

sphere  after  another,  until  the  many  perceive  what 
the  wise  few  have  always  perceived,  that  He  is  either 
everywhere  or  nowhere.  As  regards  the  realm  of 
health  and  disease,  the  dictates  of  elementary 
morality  are  clear.  Two  hundred  years  ago,  it 
might  be  argued,  the  highest  duty  of  all  just  and 
merciful  men  and  women  was  to  go  to  church  and 
join  in  the  petition  to  Heaven  "  to  preserve  all 
women  labouring  of  child."  Our  duty  now  is  to 
go  and  do  so:  this  must  we  do,  whether  or  not  we 
leave  the  other  undone;  but  if  we  will  not  do  it,  for 
the  sake  of  common  decency  let  us  not  dare  to  join  in 
the  petition  of  the  Litany. 

The  question  may  primarily  be  looked  at  from 
the  economic  point  of  view:  it  is  not  the  most  im- 
portant, nor  has  it  any  real  title  to  consideration  at 
all,  for  it  suggests  that  life  is  for  gold  and  not  gold 
for  life;  but  it  has  to  be  recognised  by  the  practical 
propagandist. 

Lately  in  Great  Britain  we  began  the  granting  of 
Old  Age  Pensions,  with  an  initial  expenditure  of 
some  twelve  million  pounds  per  annum.  Very  little 
arithmetic  is  required  to  show  what  this  sum  would 
effect,  applied  to  the  nation's  maternity.  Round 
figures  may  be  employed,  and  it  so  chances  that  they 
fit  the  memory  very  comfortably.  A  birth-rate  of 
twenty-five  per  thousand  (and  even  that  is  higher, 
I  do  not  doubt,  than  we  shall  ever  see  in  Great 
Britain  again),  in  a  population  of  forty  millions, 
means  one  million  births  per  annum.  The  figure  is 
slightly  in  excess  of  the  facts,  but  quite  near  enough 


LISTERISM  AND  MOTHERHOOD         161 

for  the  purpose.  Plainly  twelve  million  pounds  for 
a  million  births  provides  us  with  twelve  pounds  to 
dispose  of  on  each,  even  assuming  that  the  money 
was  required  in  each  case,  high  or  low. 

It  is  by  no  means  asserted  that  we  should  with- 
draw Old  Age  Pensions,  nor  yet  that  we  should 
proceed  to  spend  twelve  pounds  a-piece  on  each  con- 
finement, nor  even  that  it  would  be  wise,  without 
paternal  contributions,  to  undertake  any  State  serv- 
ice of  the  sort.  These  are  difficult  questions,  well 
worthy  of  discussion,  but  quite  outside  our  present 
need.  The  points  of  the  allusion  to  the  pensions 
are  two,  and  the  first  is  that  the  money  which  would 
be  required  for  the  adequate  care  of  every  maternity 
case  in  the  country  is  readily  available:  for  Old 
Age  Pensions  alone  consume  already  at  least  as 
much  as  would  be  required,  on  a  liberal  scale,  for 
due  attention  before,  during  and  after  every  con- 
finement in  the  land.  The  expectant  mother  might 
have  a  month's  freedom  from  work,  whatever  her 
class,  before  and  after  confinement,  and  the  pro- 
vision of  a  Listerian  nurse  and  of  a  thoroughly 
competent  and  decently  remunerated  obstetrician,  of 
either  sex,  for  twelve  pounds  or  less.  It  is  indeed 
no  less  than  astonishing  to  discover  how  relatively 
trifling  would  be  the  cost  of  such  a  practice;  and 
indeed,  in  general,  what  a  very  small  proportion  of 
the  national  income  would  be  required  for  the  vital 
purposes  of  the  nation,  compared  with  the  huge 
sums  which  are  misspent,  wasted  or  worse.  With 
one-twentieth  part  of  the  nation's  annual  expendi- 


1 62  SURGERY  AND  SOCIETY 

ture  on  alcohol  alone,  it  would  be  more  than  possible 
to  provide  due  Listerian  conditions  for  every  mother 
who  now  goes  without  them. 

But  the  argument  may  be  stated  more  forcibly 
still.  The  State  and  the  charitable  between  them 
support  a  large  number  of  hospitals,  wherein  are  to 
be  found  many  women  suffering  from  the  after- 
effects of  the  lack  of  due  attention  at  their  confine- 
ments. Allowing  nothing  for  the  economic  loss 
involved  in  these  women's  invalidism,  nor  in  that  of 
the  women,  similarly  affected,  who  never  enter  hos- 
pital wards,  we  may  well  believe  that  the  money 
now  spent  on  the  care  of  these  cases  would  suffice 
to  prevent  them  from  occurring  at  all,  and  to  save 
the  thousands  of  mothers  who  are  annually  killed 
outright  by  puerperal  fever.  But  presumably  it 
would  be  "  socialism  "  to  institute  a  service  for  ma- 
ternity, though  it  is  not  socialism  to  pay  long  and 
heavily  and  in  large  measure  fruitlessly  for  the  con- 
sequences of  the  lack  of  such  a  service. 

The  second  point  of  the  allusion  to  Old  Age 
Pensions  is  surely  no  less  evident.  How  better 
could  one  illustrate  the  difference  between  a  provi- 
dent and  an  improvident  nation,  between  statesman- 
ship and  politics?  Mothers  and  infants  have  no 
votes,  many  old  age  pensioners  and  many  more  who 
will  some  day  qualify  for  pensions  are  amongst 
those  upon  whom  politicians  depend  for  their  exist- 
ence. Motherhood  and  infancy  are  thus  ignored 
whilst  old  age  is  provided  for.  Yet  nothing  could 
be  more  evident  than  that,  if  a  wise  nation  were 
compelled  to  make  a  choice  between  provision  for 


LISTERISM  AND  MOTHERHOOD         163 

old  age  and  provision  for  infancy,  it  would  prefer 
to  begin  at  the  beginning,  in  the  belief  that  rightly 
to  provide  for  infancy  is  to  lay  the  foundations  of 
an  old  age  which  can  provide  for  itself.  Abund- 
ance of  money,  as  we  know,  is  available:  we  need 
merely  a  tiny  fraction  of  that  which  is  at  present 
spent  in  wasteful  or  disastrous  ways.  The  grant- 
ing of  Old  Age  Pensions  was,  of  course,  merely  the 
beginning  of  an  irresistible  tendency,  whereby  more 
and  more  of  the  nation's  total  superfluity  will  be 
devoted  to  its  localised  needs.  The  needy  will  be 
dealt  with,  on  the  strictest  political  principles,  in 
proportion  to  their  voting  power.  That,  at  least, 
will  be  the  sequence  unless  public  opinion  can  be 
educated  to  the  national  importance  of  the  silent 
demands  which  are  made  by  maternity  and  infancy, 
and  to  which  I  am  here  attempting  to  give  voice. 
No  doubt  the  granting  of  votes  to  women,  when  it 
comes,  will  have  the  effect  of  directing  legislation 
to  the  great  national  ends  for  which  I  plead:  the 
evidence  of  New  Zealand,  with  its  woman  suffrage, 
protection  of  maternity,  and  the  lowest  rate  of  in- 
fant mortality  in  the  Empire,  is  clear  enough  on  that 
point. 

Meanwhile  we  must  endeavour,  in  so  far  as  our 
power  lies,  to  press  the  question  home.  We  are 
handicapped,  unfortunately,  by  the  tragic  defection 
of  many  earnest  women  who  are  now  working  for 
the  vote,  the  means,  rather  than  the  end,  such  as  the 
reform  here  demanded;  and  even  more  tragic  is  the 
indignant  refusal  of  these  women  to  admit  the  right 
of  men  to  an  opinion  on  these  subjects.     But  women 


i64  SURGERY  AND  SOCIETY 

must  be  helped,  whether  they  will  or  not;  and  the 
biologist  and  physician,  who  knows  by  what  laws, 
never  named  in  legislative  chambers,  the  life  of 
nations  is  maintained,  must  devote  his  first  efforts 
to  the  needs  of  those  chosen  women  who  are  giving 
of  their  lives,  their  energies,  and  their  hereditary 
qualities,  to  the  creation  of  the  future. 

At  the  time  of  writing,  there  are  proposals  in  the 
air,  soon  to  be  incorporated  in  legislation,  whereby 
illness  is  to  be  insured  against,  with  the  aid  of  a 
substantial  contribution  from  the  State.  The  word 
insure  has  two  meanings,  fundamentally  opposed. 
We  may  take  steps  to  ensure  or  make  sure  that 
such  and  such  a  thing  shall  not  happen;  or  we  may 
take  steps  to  ensure  that,  when  it  does  happen,  there 
may  be  some  compensation.  The  difference  is  that 
between  provision  against  the  occurrence  of  fire,  and 
fire  insurance.  The  first  belongs  to  the  age  of  sci- 
ence, of  prevision,  of  causation,  of  human  control; 
the  second  to  the  age  of  "  Providence,"  "  the  in- 
scrutable decrees  of  Heaven,"  fortune-telling,  and 
all  other  forms  of  "  ignorance  in  action,"  which 
Goethe  called  the  most  dangerous  thing  in  the 
world.  It  is  not  possible  to  imagine  any  species  of 
legislation  more  fundamentally  vicious  than  that 
whereby  people  would  be  allowed  to  transgress 
every  law  of  health  until  the  due  penalty  came  upon 
them,  and  were  then  allotted  so  many  shillings  per 
week  to  spend  upon  the  futilities  of  too-late  doctor- 
ing, fortified  with  alcohol. 

But  consider  the  contrast  between  these  pitiably 
blind   proposals,   belonging   precisely  to  the   same 


LISTERISM  AND  MOTHERHOOD         165 

order  of  thought  as  the  provision  of  soup-kitchens, 
and  no  more,  for  unemployment  —  and  the  pro- 
posals already  made  in  various  parts  of  the  world, 
and  here  most  earnestly  supported,  for  insurance 
against  maternity.  Let  us  be  clear  about  this.  The 
case  is  surely  clear  enough  in  itself.  To  "  insure  " 
against  preventable  evils,  instead  of  preventing 
them,  is  folly,  alike  for  a  nation  or  for  an  individual, 
and  folly  of  the  most  mortal  kind.  To  insure 
against,  or  rather  to  provide  for,  inevitable  events, 
is  wisdom,  alike  for  a  nation  or  for  an  individual, 
and  wisdom  of  the  most  vital  kind.  I  have  else- 
where attempted  to  show  that  increasing  prevision 
and  provision  of  this  kind  is  a  mark  of  organic 
progress  as  we  see  it  in  animal  evolution.  The  two 
inevitable  events  which  transcend  and  determine  all 
others,  are  death  and  birth:  and  if  the  simple  prin- 
ciple which  I  have  attempted  to  enunciate  be  valid, 
it  is  evident  that  the  principle  of  insurance,  whether 
on  an  individual  or  a  social  basis,  must  rightly  be 
applied  to  those  two  cases  — "  life  insurance,"  so- 
called,  and  what  we  shall  some  day  be  no  less  fa- 
miliar with,  maternity  insurance.  Death  cannot  be 
prevented,  and  the  wise  man  insures  against  it; 
maternity,  the  fountain  of  life,  though  it  can  be 
stopped  up,  must  and  will  be  welcomed  and  hon- 
oured in  coming  years,  and  so  far  from  wishing  to 
prevent  it,  we  now  desire  to  encourage  it:  plainly 
here  is  a  case  for  insurance  or  provision. 

This  is  not  wholly  a  sociological  treatise;  but 
Medicine  and  Sociology  are  coming  together  nowa- 
days, never  to  be  parted,  and  the  student  of  medi- 


166  SURGERY  AND  SOCIETY 

cine  and  surgery  who  cares  not  for  their  sociological 
relations  is  to  me  an  incomplete  and  even  a  danger- 
ous person.  But  for  clearness  of  argument  I  must 
and  do  refrain  from  any  discussion  as  to  the  vastly 
important  details  of  maternity  insurance,  save  only 
to  reassert  my  long-held  but  ever-growing  convic- 
tion that  on  no  account  whatever  must  we  do  any- 
thing which  defies  the  seonian  lessons  of  natural  his- 
tory by  making  it  less  instead  of  more  responsible 
to  be  a  father.  In  pursuance  of  this  clear  natural 
indication  —  of  which  the  institution  of  marriage  is, 
of  course,  the  human  expression  —  I  earnestly  hope 
that,  in  whatever  scheme  of  illness  insurance  ulti- 
mately takes  shape,  exacting  some  toll  from  the 
workman,  provision  will  be  made  for  his  wife,  and 
her  maternal  illness,  which  stands  over  and  against 
every  other  form  of  illness  or  disablement  that  can 
be  imagined.  Those  make  for  death,  this  makes 
for  life:  and  nothing  is  worthy  of  the  name  of 
statesmanship  which  does  not  recognise  this  deepest 
of  differences.  The  needs  of  maternity  are  abso- 
lutely unique:  we  do  not  want  consumptive  or  alco- 
holic workmen  or  bedridden  senile  paupers,  or 
lunatics  or  the  feeble-minded,  and  our  duty  is  to 
prevent  such  things  from  existing  at  all;  but  we  do 
want  the  woman  labouring  of  child,  we  want  her  all 
the  more,  nationally,  because  she  is  being  less 
wanted,  individually,  and  because,  as  a  community, 
we  are  at  present  vastly  more  successful  in  prevent- 
ing birth  than  in  preventing  death;  and  therefore 
we  must  provide  for  her,  and  for  her  first. 

The  fall  in  the  birth-rate  is  mainly  voluntary,  but 


LISTERISM  AND  MOTHERHOOD         167 

it  is  by  no  means  entirely  so.  No  matter  whether 
we  consider  the  voluntary  factor  or  the  involuntary 
factor,  the  argument  in  favour  of  due  Listerism  for 
all  our  motherhood  is  clear.  The  voluntary  factor 
is  by  no  means  wholly  paternal  and  economic,  as 
many  suppose.  The  mothers  desire  to  limit  their 
families,  quite  apart  from  the  question  of  money, 
because  child-bearing  is  heavy  labour,  and  frequent 
child-bearing  more  than  body  and  mind  can  usually 
bear.  Therefore  we  must  at  least  provide  the  very 
best  conditions  for  maternity;  and  here  Listerism 
does  undoubtedly  appear  as  in  some  measure  the 
social  antidote,  so  to  say,  for  what  is  called  Neo- 
Malthusianism.  It  offers  the  mother  the  practical 
certainty  of  safety,  quick,  easy,  uncomplicated  re- 
covery, and  total  absence  of  disabling  or  painful 
sequela  of  any  kind. 

The  involuntary  factor  of  the  fall  in  the  birth- 
rate is  smaller  than  the  voluntary,  and  has  been  in- 
adequately reckoned  with  since  we  came  generally 
to  recognise  the  existence  of  the  voluntary  factor. 
This  last,  however,  as  the  name  implies,  is  control- 
lable; the  other,  outside  any  obvious  control,  may 
really  be  by  far  the  more  minatory  of  the  two.  It 
seems  clear  that  involuntary  sterility,  definitely  due 
to  the  mothers  and  not  to  the  fathers,  is  steadily 
increasing  in  our  highly  civilised  communities.  A 
higher  proportion  of  infants  die  from  premature 
birth,  involuntary  miscarriage  is  certainly  not  di- 
minishing, and  there  is  the  immensely  significant  in- 
dication furnished  by  the  increasing  incapacity  of 
mothers  to  nurse  their  children.     This  I  take  to  be 


168  SURGERY  AND  SOCIETY 

an  early  symptom  of  reproductive  failure.  It 
means  more  even  than  that,  as  I  have  often  said, 
woman  is  ceasing  to  be  a  mammal.  It  means  that 
she  is  ceasing  to  be  a  mother:  and  what  then?  The 
reproductive  system  is  one,  we  must  remember. 
Part  of  it  is  for  the  ante-natal  nurture,  part  of  it  for 
the  post-natal  nurture,  of  the  child:  but  womb  and 
breasts  are  parts  of  a  whole,  are  profoundly  con- 
nected by  nervous  and  by  subtle,  indissoluble  chem- 
ical bonds;  and  loss  of  function  in  the  one  case 
presages  and  indeed  probably  often  accompanies, 
even  already,  loss  of  function  in  the  other. 

Here,  surely,  is  another  reason  why  maternity 
must  be  made  as  feasible  and  as  safe  as  possible  for 
those  women  who  undertake  it,  and  why,  the  pos- 
sible mothers  of  the  races  becoming  fewer,  we  must 
avert  the  dangers  which  now  kill  many  of  them 
every  year,  and  disable  for  all  future  maternity 
many  more. 

This  chapter  is  already  of  considerable  length, 
and  has  included  some  discussion  —  in  reality  most 
brief  and  merely  indicative  —  of  questions  which  are 
not  primarily  surgical,  and  may  seem  to  have  little 
bearing  on  our  subject.  It  might  be  argued  with 
some  force,  however  inadequate  the  present  illustra- 
tion, that  the  best  service  which  a  thinker  can  ren- 
der is  to  show  the  connexion,  the  mutual  depend- 
ence, and  possibility  of  application,  of  things  which 
appear  independent  and  disparate.  This  is  as- 
suredly true  in  the  natural  sciences,  and  I  do  not  see 
why  it  should  not  be  true  in  sociology,  which  is  of 


LISTERISM  AND  MOTHERHOOD         169 

the  same  order  as  biology  or  physics,  differing  in  no 
essential.  Thus  it  might  be  that  the  sociologist  can 
perform  no  higher  service  than  to  show  the  bear- 
ing of  one  fact  of  our  social  life  upon  another;  and 
to  me  it  seems  evident  that  the  bearing  of  Listerism 
upon  our  falling  birth-rate  is  notable  and  hopeful. 
If  it  really  exists,  it  is  certainly  urgent,  for  the  fall 
in  the  birth-rate,  however  familiar  it  may  have  now 
become,  is  really  sensational  and  stupendous  in  its 
meaning.  The  hortatory,  episcopal,  truculently 
moral  school  of  critics  have  failed  and  will  fail. 
There  is  no  right  course  but  one,  which  has  only  to 
be  stated  to  be  accepted.  It  is  to  honour,  elevate, 
safeguard  and  purify  parenthood;  and  in  this  chap- 
ter it  has  been  sought  to  prove  that  Listerism  may 
be  and  will  be  of  high  and  indispensable  service  in 
this  respect. 

Thus  the  professing  Eugenist,  turning  aside  from 
his  own  subject  for  once,  finds  himself  returning  to 
it  unawares.  There  is  no  getting  away  from  parent- 
hood, because  there  is  no  getting  away  from  life 
and  death.  The  gross  need  for  surgery  is  going, 
one  needs  only  the  use  of  the  most  mediocre  eyes  to 
see  the  end  of  it;  but  motherhood  must  not  go  and 
will  not  go.  When  the  day  comes  that  finds  the 
surgical  instruments  of  to-day  almost  confined  to 
museums,  when  surgery,  notwithstanding  its  rapid 
but  transient  extension  to  all  manner  of  hitherto 
exclusively  medical  fields,  is  confined,  for  lack  of  de- 
mand, to  little  more  than  cases  of  accident  —  Na- 
ture's amazing  operation  of  childbirth  will  still  be 


170  SURGERY  AND  SOCIETY 

daily  or  nightly  performed,  and  beside  those  beds, 
centuries  and  centuries  of  centuries  hence,  will  stand 
Lord  Lister,  still  saving  the  mothers  of  men. 

In  Great  Britain  the  Midwives  Act  has  done 
something,  undoubtedly,  for  motherhood;  but  that 
is  only  a  beginning.  We  require  a  Public  Ma- 
ternity Service  which,  under  some  economic  system 
or  other,  will  provide  the  necessities  formulated  by 
modern  Listerian  obstetrics  for  every  mother  in  the 
land,  married  or  unmarried.  This  will,  of  course, 
be  part,  the  most  important  and  permanent  part  — 
for  all  other  forms  of  illness  are  going  —  of  the 
National  Medical  Service  of  the  future,  which  will 
be  primarily  and  mainly  preventive,  but  will  also 
deal  efficiently  with  the  one  form  of  illness  which 
we  do  not  wish  to  prevent. 

[The  foregoing  is  printed  as  it  was  written  before 
hearing  Mr.  Lloyd  George's  epoch-making  speech 
in  the  House  of  Commons  (May  4,  191 1).  In  a 
later  chapter  will  be  found  some  discussion  of  the 
possibilities  in  this  new  age  now  dawning.] 


CHAPTER  IX 

LISTERISM  AND  WAR 

We  have  seen  how  a  practice  designed  to  raise  the 
patient's  chances  of  recovery  after  amputation  for 
compound  fracture,  has  come  to  be  applied  to  ma- 
ternity, and  has  there  proved  no  less  beneficent 
than  chloroform  or  the  obstetric  process.  The 
needs  of  mothers  were  not  in  Lister's  mind,  nor  in 
that  of  Pasteur  before  him,  though  the  hour  was  at 
hand  when  Pasteur  was  to  identify  the  coccus  of 
puerperal  fever,  and  the  application  of  Listerism 
was  forever  to  remove  the  reproach  that  the  world's 
maternity  hospitals  were  more  deadly  than  its  bat- 
tlefields. 

Alike  where  men  are  slain  and  where  babes  are 
born,  in  their  turn  to  slay  or  save,  Listerism  finds 
its  work  to  do,  and  in  the  present  chapter  we  may 
look  at  the  place  of  Listerism  on  the  battlefield  or 
the  ironclad,  and  in  the  military  hospital.  We  thus 
return,  in  a  sense,  to  the  earlier  and  more  obvious 
applications  of  Listerism,  from  such  later  develop- 
ments as  followed  upon  the  discovery  of  its  rele- 
vance to  the  needs  of  childbirth. 

Yet  in  a  sense  the  order  of  these  two  chapters  is 
chronological.  It  is  indeed  true  that  the  method 
first  employed  to  lower  the  death-rate  after  ampu- 
tations might  be  expected,  having  signally  and  in- 

171 


172  SURGERY  AND  SOCIETY 

stantly  proved  its  powers  in  that  direction,  to  find  a 
place  at  once  in  military  surgery  above  all.  Yet  it 
was  not  so.  The  obstetricians,  professional  sav- 
iours of  life,  accepted  the  new  discovery  before  the 
military  authorities,  professional  destroyers  of  life. 
We  have  seen  that  carbolic  acid  entered  the  ma- 
ternity hospitals  in  the  seventies,  at  any  rate  in 
Edinburgh  and  Paris,  but  not  until  the  last  great 
campaign  in  the  world's  history  were  the  principles 
of  Listerism  fully,  or  even  at  all  adequately,  applied 
in  war  —  and  then  in  circumstances  which  the  his- 
torian may  well  record  with  amazement. 

Be  it  again  noted,  first,  that  the  Franco-Prussian 
War  followed  upon  the  immeasurably  greater  event, 
the  winning  campaign  in  the  agelong  war  between 
microbes  and  men,  just  long  enough  for  the  soldiers 
in  that  terrible  struggle  to  profit,  had  the  intelli- 
gence been  available,  by  the  work  already  done  in 
Paris,  Glasgow,  and  Edinburgh.  Huxley  pointed 
out  that  Pasteur's  services  to  the  industries  of  France 
sufficed  to  provide  the  entire  indemnity  which  she 
paid  to  Germany  after  the  war.  But  he  did  not 
point  out,  as  he  might  well  have  done,  had  he  lived 
to  see  the  Russo-Japanese  War,  that  if  the  work  of 
Pasteur,  applied  by  Lister,  had  been  used  by  the 
French  military  authorities,  not  only  might  there 
have  been  no  indemnity  for  France  to  pay,  but  she 
might  have  had  one  to  receive.  Neither  side  knew 
aught  of  what  had  been  done;  alike  as  regards  in- 
fection with  the  soldiers'  curses,  typhoid  and  its 
congeners,  and  as  regards  the  treatment  of  wounds, 
they  fought  as  in  the  ages  of  darkness,  excepting 


LISTERISxVI  AND  WAR  173 

only  that  the  wretched  victims  who  required  the 
surgeon's  dirty  knife  were  spared  the  immediate 
pain  of  operation,  by  the  use  of  Simpson's  chloro- 
form. That  was  twenty-three  years  old,  and  had 
already  penetrated  the  plugged  ears  of  War  Offices. 
A  generation  or  so  later,  President  Kruger's 
threat  to  "  stagger  humanity  "  was  fulfilled  in  the 
Boer  War.  As  the  countrymen  of  Pasteur  were 
concerned  in  the  earlier  campaign,  so  the  country- 
men of  Lister  were  concerned  in  the  later.  Cer- 
tainly military  surgery  had  been  transformed  in  the 
interval,  and  the  principles  of  Listerism  were  ap- 
plied to  some  extent  everywhere.  At  any  rate  the 
stage  of  antiseptic  surgery  was  reached.  Fellow- 
students  of  the  present  writer  in  Edinburgh,  where 
the  Listerian  tradition  was  so  recent  and  illustrious, 
left  the  class-rooms,  Boers  and  British  to  fight  and 
to  serve  as  surgeons  and  dressers,  on  their  respective 
sides.  A  writer  who  witnessed  the  departure  of 
friends,  till  then  engaged  in  common  and  sympa- 
thetic study  of  the  greatest  art  of  Peace,  for  a  field 
on  the  other  side  of  the  Equator,  where  they  were 
to  endeavour  to  blow  each  other's  brains  out,  may 
be  excused  for  stating  his  belief  that  seldom  can 
the  sun  have  witnessed  a  fouler  business  than  that 
war.  But  at  least  there  was  Listerism  practised  by 
and  for  both  sides,  and  if  one  were  a  biometrician, 
ready  to  accept  as  trustworthy  data  anything  capa- 
ble of  expression  in  figures,  this  would  be  the  place 
to  cite  evidence  showing  that  the  practice  of  Lister- 
ian surgery  was  the  one  bright  spot  in  all  that  hide- 
ous   and   futile   business.     Professor   John    Chiene, 


174  SURGERY  AND  SOCIETY 

who  had  been  Lister's  right  hand  man  when  the 
precious  seed  was  beginning  to  grow  in  Edinburgh, 
did  notable  work  of  direction  and  personal  practice 
in  South  Africa,  and  it  would  ill  become  a  writer 
who  owes  to  him  the  most  inspiring  and  vivid  Lis- 
terian  teaching,  and  the  first  hearing  of  the  great 
name,  to  question  that  in  the  Boer  War,  Lord 
Lister's  influence  was  beneficent  and  unprecedented 
in  military  annals. 

But  it  cannot  be  denied  that  the  pathological 
record  of  that  campaign  is  a  black  one.  The  fault 
was  not  that  of  the  military  surgeons,  nor  the  civilian 
doctors,  nor  the  dressers,  nor  the  many  faithful 
nurses,  Listerians  one  and  all,  who  did  their  best 
through  all  that  long  tragedy.  It  lay  with  the  War 
Office  and  the  professional  soldiers  at  whose  mercy 
were  the  medical  and  surgical  dispositions  from  first 
to  last.  Those  who  should  know,  for  they  served 
upon  the  spot,  have  assured  me  that  the  medical 
part  of  the  campaign,  lamentably  inadequate  though 
it  was,  at  least  surpassed  the  standard  of  the  other 
services.  Ignorance,  arrogance,  incompetence,  and 
every  other  attribute  favourable  to  failure,  were 
our  abundant  portion  in  the  Boer  War.  The  men 
who  could  do  nothing  right  in  their  own  depart- 
ments, every  detail  of  which  was  supposed  to  be 
familiar  to  them,  could  scarcely  be  expected  to  rec- 
ognise the  importance  of  medical  science,  of  which 
they  knew  nothing,  and  which  their  whole  education, 
from  public  school  days  onwards,  had  taught  them 
to  despise.  And,  of  course,  things  were  bad 
enough,   from  the  military  point  of  view,  without 


LISTERISM  AND  WAR  175 

the  addition  of  further  worries  and  restraints  and 
proposals  from  the  medical  officers.  Thus  it  was 
that  the  most  elementary  requirements  of  hygiene 
and  preventive  medicine  were  defied;  and  it  was  not 
the  fault  of  the  non-medical  persons  concerned  if 
the  appalling  records  of  the  Crimea  were  not 
rivalled. 

The  British  forces  lost  far  more  lives  by  disease 
than  by  the  Boer  bullets.  The  surgeons  saved 
many  lives  and  limbs  which  in  any  previous  cam- 
paign in  the  world's  history  would  have  been  lost. 
But  if  the  principles  upon  which  the  surgeons  pro- 
ceeded had  been  acted  upon  as  they  should  and 
could  have  been,  the  total  loss  of  life  would  have 
been  halved,  at  the  least,  and  the  campaign  ended, 
very  likely,  in  half  the  time.  For,  as  we  have  al- 
ready seen,  Listerism  is  only  one  application  of  the 
work  of  Pasteur.  It  is  simply  one  department  of 
applied  bacteriology.  The  whole  science  of  epi- 
demics is  substantially  another.  The  conveyance  of 
surgical  fever  from  one  patient  to  the  previously 
clean  wound  of  another  is  essentially  one  and  the 
same  thing  as  the  infection  of  consumption  by  the 
inhalation  of  tubercle  bacilli  which  a  patient  has 
expectorated,  or  of  typhoid  or  dysentery  by  a  simi- 
lar process.  In  all  these  cases  we  have  to  deal  with 
a  parasitic  disease  spread  by  conveyance  of  the  par- 
asites from  the  sick  to  the  sound. 

All  this,  to  the  medically-trained  mind,  is  simply 
alphabetical.  The  doctor  has  been  taught,  and  has 
abundantly  satisfied  himself,  that  these  are  the 
fundamental  matters  of  life  and  death,   absolutely 


176  SURGERY  AND  SOCIETY 

simple,  perfectly  certain,  never  to  be  forgotten  or 
neglected  for  one  moment  in  any  circumstances 
whatever.  When  it  is  proposed  to  pitch  camp  on 
ground  saturated  with  typhoidal  drainage,  this  is  to 
him  a  hideous  and  criminal  insanity,  practically 
equivalent  to  wholesale  and  deliberate  murder.  To 
the  non-medical  mind  none  of  these  considerations 
have  any  substantial  meaning,  and  the  medical  pro- 
test is  at  once  brushed  aside,  on  account  of  over- 
whelming "  military  "  reasons  which  a  non-combatant 
cannot  be  expected  to  understand.  In  the  im- 
mortal words  of  Lord  Wolseley,  "  Medical  advice  is 
a  very  good  thing  —  when  it  is  asked  for";  which 
is  quite  equal,  in  its  way,  to  Lord  Roberts'  demand 
for  military  training,  whilst  recruits  are  being  re- 
jected on  all  hands,  and  the  neglect  of  infancy  dam- 
ages for  life  two-thirds  of  our  population.  The  one 
soldier  could  no  more  see  that  medical  advice  is 
never  more  wanted  than  by  those  who  are  too  igno- 
rant to  ask  for  it,  than  the  other  can  see  that  you 
cannot  have  a  soldier  until  you  have  first  saved  and 
served  a  baby. 

To  consider  the  question  of  military  surgery  and 
to  ignore  the  two  diseases,  typhoid  and  dysentery, 
on  the  ground  that  they  are  "  medical,"  would  be 
simply  to  perpetuate  a  distinction  which,  as  Pasteur 
taught  us,  has  no  real  meaning;  and  we  shall  see, 
when  we  compare  the  Boer  War  with  the  Russo- 
Japanese  War,  that  the  principles  of  Pasteur's  pre- 
ventive medicine  are  equally  applicable  to  the  in- 
fection which  is  the  vital  factor  in  the  one  case  as 
to  that  which  is  the  vital  factor  in  the  others.     In 


LISTERISM  AND  WAR  177 

the  Boer  War  we  had  a  medical  and  surgical  service, 
but  it  was  designed  to  be  curative,  not  preventive. 
The  most  limited  intelligence  can  perceive  the  use 
of  a  doctor  when  a  man  is  bleeding  to  death:  but 
the  subtle  objection  to  pitching  camp  upon  typhoid 
excrement,  or  drinking  water  into  which  a  dysenteric 
hospital  drains,  requires  something  like  a  mind  to 
perceive.  Thus  the  death-rate  from  typhoid  fever 
and  dysentery  amongst  the  British  forces  was  mon- 
strous and  appalling  —  the  Boer  bullets  were  harm- 
less by  comparison.  And  this  was  amongst  the  rep- 
resentatives of  the  nation  which  led  and  still  leads 
the  world  in  the  primary  sanitation  of  its  cities. 

Broadly,  then,  it  is  true,  as  has  been  already  sug- 
gested, that  our  medical  and  surgical  service  in  the 
Boer  War  represented  the  stage  of  intelligent  at- 
tempts to  cure,  and  no  more.  There  were  beds  and 
drugs  and  invalid  food  and  nurses  for  the  victims  of 
the  epidemics,  but  those  in  command  knew  little  or 
nothing  of  the  prevention  of  epidemics,  and  the  doc- 
tors had  to  do  the  little  they  could.  And  for  the 
surgical  cases,  infected  in  various  ways,  there  was 
the  primitive  Listerism  of  carbolic  acid,  perchloride 
of  mercury,  and  the  rest  of  the  antiseptic  parapher- 
nalia: admirable,  invaluable  in  its  way,  but  always 
a  last  resort,  always  the  expression  of  previous  fail- 
ure. What  more  could  one  expect  in  the  surgery 
of  wounds  not  inflicted  by  Listerian  surgeons,  but 
by  the  bullets  of  the  enemy?  the  reader  may  ask. 
We  shall  see. 

For  now  we  turn  to  the  case  of  the  next  great 
campaign,    the    Russo-Japanese   War  —  where    the 


178  SURGERY  AND  SOCIETY 

victory  was  not,  as  in  our  case,  to  the  many  but  to  the 
few.  As  everyone  knows,  this  was  by  far  the  most 
bloody,  by  far  the  most  colossal  campaign  in  history. 
There  are  no  precedents,  at  any  rate  in  modern 
times,  for  the  numbers  engaged  and  the  magnitude 
of  the  death-roll :  and  if  we  consider  the  size  of  an- 
cient populations,  we  shall  see  that  there  never  can 
have  been  anything  to  compare  with  that  war.  So 
huge  and  continuous  was  the  slaughter  that  numbers, 
as  numbers,  told,  not  because  big  battalions  beat 
little  ones,  but  because  of  the  drain  upon  the  availa- 
ble manhood  of  the  contestants.  It  was  as  in  a  law- 
suit, where  the  longest  purse  wins.  The  Japanese 
had  the  enormous  disadvantage  of  a  relatively  small 
population  —  the  ravages  wrought  in  which  they  are 
now,  with  the  most  remarkable  expression  of  patriot- 
ism in  history,  repairing  by  means  of  a  greatly  raised 
birth-rate  —  and  it  is  generally  agreed  that  they 
could  scarcely  have  held  out  any  longer  when  at  last 
peace  was  declared. 

Now  the  Russian  losses  from  disease  of  all  kinds, 
from  the  infections  such  as  typhoid  and  dysentery, 
and  from  that  other  infection  called  surgical  fever, 
were  enormous.  Nothing  else  could  have  been  ex- 
pected from  the  conditions  of  the  campaign,  and 
from  the  limitless  ignorance,  carelessness,  alcohol- 
ism, disloyalty  and  corruption  which  marched  for- 
ward, under  the  Cross  of  Christ,  to  conquer  the 
"  yellow  monkeys."  And  if  we  contrast  the  Russian 
losses  from  these  preventable  causes  with  those  sus- 
tained by  their  enemies  from  the  same  causes  under 
identical  climatic  and  seasonal  conditions,  we  shall 


LISTERISM  AND  WAR  179 

find  ourselves  bound  to  agree  with  Sir  Frederick 
Treves,  and  confess  that  that  war  was  won  for  the 
Orientals  against  the  Westerns  by  the  fact  that 
Western  science  weighed  down  the  scales  on  the 
Eastern  side.  Not  less  than  Togo  and  the  rest, 
Pasteur  and  Lister  won  that  war  for  Japan. 

For  observe  what  was  done.  Everyone  knows 
that  the  Japanese  have  adopted  Western  science, 
and  not  only  prejudiced  observers,  unacquainted  with 
the  facts  at  first  hand,  but  also  such  a  writer  as 
Lafcadio  Hearn,  have  deplored  the  consequent 
changes  that  have  come  over  the  land  of  the  Rising 
Sun.  The  Japanese  have  indeed  abandoned  many 
of  their  virtues  in  favour  of  our  vices,  and  pity  'tis, 
'tis  true.  But  to  admit  that  is  not  by  any  means  to 
admit  the  argument  of  those  who  declared,  espe- 
cially during  the  war,  that  the  Japanese  had  simply 
taken  over  from  us  the  worst  features  of  our  civilisa- 
tion and  none  other.  Some  said  that  it  was  the 
mark  of  the  lowness  and  essential  inferiority  of  this 
Mongolian  race  —  which,  by  the  way,  has  larger 
brains  than  the  white  race,  whatever  that  may  por- 
tend for  the  future  —  that,  when  they  studied  West- 
ern ways,  they  simply  picked  out  the  gunpowder  and 
cannon,  the  warships  and  torpedoes,  the  instruments 
of  war,  slaughter  and  death.  It  was  not  the  useful 
or  the  beautiful  or  the  noble  that  they  wanted  from 
the  West,  but  the  power  to  kill  more  efficiently,  and 
that  alone. 

Well,  of  all  the  features  of  our  Western  civilisa- 
tion, it  is  very  certain  that  some  will  pass  and  some 
will  remain;  the  world  will  not  always  want  war- 


i8q  SURGERY  AND  SOCIETY 

ships,  but  it  will  always  want  Listerism  —  at  any 
rate  so  long  as  it  wants  babies.  And  if  we  were  to 
attempt  to  anticipate  the  verdict  of  ten  or  five  or 
two  centuries  hence  upon  our  own  days,  we  might 
well  guess  that  the  practical  applications,  in  medicine 
and  surgery,  of  Pasteur's  bacteriology  would  take 
a  foremost  place  in  the  critical  estimation  of  the 
future.  The  nineteenth  century  gave  us  Pasteur, 
after  all,  as  well  as  Krupp,  and  Koch  as  well  as 
Bismarck.  Now  before  we  dismiss  the  Japanese 
for  having  valued  and  copied  only  our  vices  and 
our  infernal  devices,  let  us  acquaint  ourselves  with 
the  fact  that  they  have  also  taken  the  work  of  Pas- 
teur and  Koch,  of  Simpson  and  Lister,  and  that  they 
have  already  applied  it  as  it  was  never  applied  before 
—  else  Russia  might  well  be  the  suzerain  of  Japan 
at  this  hour.  The  new  sciences  of  healing  and  saving 
were  born  in  France  and  Britain,  and  developed 
there  and  in  Germany :  in  two  great  campaigns  since 
1870  all  three  of  these  nations  have  been  engaged, 
but  it  was  left  for  Japan,  for  the  "  yellow  monkeys  " 
of  the  Orient,  incredibly  alien  in  temperament,  tra- 
dition and  practice,  to  apply  in  war,  for  the  con- 
quest of  a  Western  state,  the  principles  which  France 
and  Britain  and  Germany  have  given  to  mankind. 
I  know  of  nothing  in  the  human  record  at  all  com- 
parable to  this  most  extraordinary  and,  at  first  sight, 
wildly  inexplicable  fact:  and  if  ever  there  lived  a 
man  wise  enough  to  have  predicted  it,  I  should  like  to 
know  his  name. 

In  South  Africa  we  reached  the  application  of  the 
primitive  Listerism  which  faces  dirty  wounds  and 


LISTERISM  AND  WAR  181 

treats  them  with  carbolic  acid.  That  is  antiseptic 
surgery.  But,  as  has  already  been  seen,  there  is 
a  stage  beyond  that,  where  wounds  are  made  clean 
from  the  first,  and  not  only  have  no  need  of  carbolic 
acid,  but  heal  more  rapidly  and  neatly  without  it. 
Quite  so,  the  reader  may  reply,  but  what  has  that 
to  do  with  the  wounds  made  in  war?  Unlike  the 
rifleman,  the  aseptic  surgeon  cleans  the  patient's 
skin,  mechanically  and  to  some  extent  chemically, 
he  purifies  his  own  fingers  and  sterilises  by  heat  the 
instruments  with  which  he  makes  his  wounds. 

Yet  there  must  be  some  heat,  if  we  think  of  it, 
associated  with  a  rifle-bullet.  A  very  high  tempera- 
ture is  produced  by  the  explosion  which  sends  it  on 
its  way.  That,  indeed,  lasts  but  an  infinitesimal 
fraction  of  a  second.  But  during  its  passage 
through  the  air  the  rotating  bullet  is  doubly  steril- 
ised: first,  by  the  intense  and  irresistible  scrubbing 
to  which  the  friction  of  the  atmosphere  subjects  it, 
and  secondly,  by  the  heat  which  that  friction  de- 
velops. 

Thus  we  reach  a  very  notable  and  remarkable 
conclusion,  the  due  significance  of  which  the  Jap- 
anese were  the  first  to  perceive,  as  we  shall  see.  It 
is  that  the  instruments  by  which  wounds  are  in- 
flicted in  modern  warfare  are  sterile,  like  the  knife 
of  the  Listerian  surgeon.  He  sterilises  his  knife  by 
heat,  and  so  also  does  the  soldier  sterilise  his  bullet. 
Wounds  in  warfare  are  doubtless  made  in  other  ways, 
as  by  the  sword;  but,  as  we  all  know,  these  other 
ways  are  nowadays  quite  insignificant,  as  compared 
with  the  rifle  bullet.     Other  types  of  missile  may 


1 82  SURGERY  AND  SOCIETY 

be  used  for  wounding  warships,  and  will  occasionally 
hit  men;  but  in  so  far  as  modern  war  is  determined 
by  the  wounding  of  men,  the  rifle  bullet  is  the  one 
instrument  we  need  consider:  and  it  is  aseptic. 

However,  the  aseptic  surgeon  cannot  content  him- 
self with  the  sterilisation  of  his  instruments,  for  his 
success  depends  upon  his  control  of  everything  which 
may  infect  the  wound  he  makes;  and  if  he  were 
compelled  to  operate  not  only  upon  uncleansed  skin 
but  also  through  uncleansed  clothes,  he  would  cer- 
tainly argue  that  no  good  could  be  expected  from 
the  previous  sterilisation  of  his  instrument  merely. 
Nor  would  he  be  better  pleased  if  the  operation  were 
to  be  so  performed  as  to  carry  a  portion  of  the  pa- 
tient's clothing  into  the  wound,  as  on  the  point  of  a 
probe,  and  leave  it  there. 

But  that  is  what  happens  in  war.  The  perfectly 
sterilised  bullet  strikes  always  upon  unsterilised  skin, 
and  in  the  great  majority  of  cases  has  to  traverse 
a  layer  of  clothing  before  it  can  reach  the  skin  at 
all.  If  we  attempt  to  make  some  allowance  for  the 
conditions  of  warfare,  so  far  from  bath-rooms  and 
wardrobes,  if  we  allow  for  the  influence  of  heavy 
marching  upon  the  skin,  and  if  we  acquaint  our- 
selves —  but  it  is  better  not  to  —  with  the  soldier's 
allowance  in  the  matter  of  underclothing  —  we  shall 
see  that  not  even  the  modern  aseptic  bullet  can  be 
expected  to  perform  an  aseptic  operation  under,  or 
through,  these  conditions.  And  if,  as  often  hap- 
pens, some  of  the  clothing  is  carried  into  the  wound 
—  there  will  be  much  need  for  carbolic  acid  as  soon 
as  it  can  be  applied. 


LISTERISM  AND  WAR  183 

Consider  now  the  case  of  a  race  which  is  asked  to 
enter  upon  a  campaign  for  its  national  existence, 
and  which  is  characterised  by  certain  marked  na- 
tional peculiarities.  In  the  first  place,  the  Japanese 
are  admittedly  the  cleanest  people  in  the  world:  or 
at  least  they  were,  until  lately,  on  their  own  soil. 
(It  is  no  more  possible  to  make  sure  of  the  main- 
tenance of  the  Japanese  cleanliness  in  contact  with 
European  civilisation  than  of  Jewish  sobriety  under 
similar  conditions,  no  matter  how  long  nor  how 
solid  and  continuous  be  the  racial  tradition  in  either 
case.)  We  all  know  that  the  Japanese  crowd  is 
non-odorous,  even  in  still  air  and  warm  weather; 
and  readers  who  have  noses  will  recall  Western  ex- 
periences of  crowds,  of  which  the  less  said  the  better. 
This  cleanliness  is  dependent,  as  all  cleanliness  must 
be,  upon  two  factors,  neither  of  which  will  be  ef- 
ficient without  the  other:  the  skin  must  be  daily 
cleansed,  and  the  clothing  must  be  renewed  with 
very  great  frequency.  If  any  comforting  considera- 
tion may  be  quoted  for  those  who  know  but  do  not 
care  for  the  flavour  of,  say,  a  carriage  in  the 
M  tubes  "  of  London,  or  its  motor-buses,  it  is  that 
probably  the  clothes  are  more  active  than  the  skins 
in  contribution  thereto.  Now  the  Japanese  is  not 
only  forever  bathing,  but  he  keeps  his  underclothing 
clean :  or  at  any  rate  he  does  and  did  except  and  until 
he  meets  us. 

Generally  speaking,  it  seems  that  we  are  teaching 
him  to  be  more  or  less  dirty;  but  in  the  remarkable 
instance  under  discussion,  we  taught  him  to  be 
cleaner    than    ever.     Prior    to    the    Russo-Japanese 


1 84  SURGERY  AND  SOCIETY 

War  the  Japanese  had,  of  course,  adopted  and  be- 
gun to  cultivate  Western  bacteriology  as  well  as 
Western  ordnance  and  alcohol.  In  the  laboratories 
of  Koch  and  Behring  Japanese  students  had  indeed 
added  substantially  to  the  progress  of  the  science, 
as  in  the  making  of  the  diphtheria  antitoxin,  the 
discovery  of  the  bacillus  of  lockjaw  by  Kitasato,  the 
identification  of  the  bacillus  of  one  form  of  dysen- 
tery by  Shiga,  and  so  forth.  Thus,  there  was  no 
question  that  they  would  avail  themselves  of  the 
work  of  Lister.  And  here  two  national  character- 
istics came  to  their  service:  first,  their  customary 
cleanliness,  and  second,  their  extreme  attention  to 
and  supervision  of  detail.  These  two  things  are,  in- 
deed, the  very  best  imaginable  as  preliminary  pos- 
sessions of  him  who  would  become  a  Listerian. 

And  so  it  came  about  that  when  a  naval  engage- 
ment was  imminent  the  Japanese  sailors  were  all 
ordered  to  take  a  bath  with  some  disinfectant  and  to 
don  clean,  freshly-boiled  underclothing. 

It  need  not  be  asserted  that  they  had  all  heard 
of  Pasteur,  and  knew  the  theory  of  surgical  inflam- 
mation. No  doubt  the  orders  were  carried  out  in  a 
quite  unintelligent  way;  and  I  should  incline  to  sup- 
pose that  the  spirit  of  their  execution  was  religious 
rather  than  scientific.  All  cleanliness  tends  to  be 
next  to  godliness  in  the  psychological  sense;  it  is 
a  semi-religious  ritual  to  make  oneself  clean  at  cer- 
tain fixed  hours,  one  feels.  The  Japanese  sailor 
would  feel  this,  too;  and  there  would  be  added  to 
this  natural  psychological  tendency  the  powerful  mo- 
tive furnished  by  the  fact  that  these  were  the  orders 


LISTERISM  AND  WAR  185 

of  his  Emperor,  Heaven-descended,  for  whom  he 
was  about  to  face  death.  I  dwell  upon  this  ques- 
tion not  so  much  for  its  inherent  interest,  which  is 
surely  considerable,  as  for  its  bearing  upon  the  pos- 
sibility of  applying  the  principles  of  aseptic  surgery 
to  our  own  forces.  For  the  Japanese  it  was  enough 
that  these  were  the  orders  given  in  the  name  of  his 
Divine  Emperor,  orders  appealing  to  an  obedience 
rigorously  trained  from  childhood,  and  to  a  loyalty 
which  had  the  full  force  of  a  supreme  religious  im- 
perative. Add  the  customary  cleanliness  of  the 
race,  and  we  realise  that  this  process  of  preliminary 
sterilisation  must  have  been  carried  out  in  no  per- 
functory way,  but  in  the  spirit  and  to  the  limit  of 
the  letter.  Now  it  would  evidently  be  by  no  means 
the  same  problem  to  enforce  Listerism  upon  the 
British  "  Tar "  or  "  Tommy,"  trained  neither  in 
cleanliness  nor  in  detailed  obedience,  inclined  to 
grumble  at  every  order  of  which  he  does  not  see 
the  utility,  and  entirely  without  the  superstitious- 
religious  factor  of  conduct  which,  beyond  all  things, 
saved  Japan  in  her  extremity.  The  problem  for  us 
must  be  solved  through  the  intelligence,  rather  than 
the  habits  and  the  emotions,  of  the  soldier,  and  be- 
fore this  chapter  is  concluded,  that  question  must  be 
considered. 

Meanwhile  let  us  observe  that  the  Japanese  sailor, 
thus  prepared,  stood  up  to  meet  his  enemy  in  an 
entirely  new  kind  of  military  armour.  His  prede- 
cessors of  a  generation  ago,  as  one  could  observe  at 
the  Japanese  War  Office's  Exhibit  at  the  Anglo-Jap- 
anese Exhibition  in  London  in  19 10,  had  been  ar- 


186  SURGERY  AND  SOCIETY 

rayed  in  armour  of  wood  and  steel,  chain  and  plate, 
after  the  fashion  of  soldiers  in  all  ages :  but  he  stood 
up  in  the  full  panoply  of  a  carbolised  skin  and  a 
boiled  shirt.  And  thus  he  substantially  guaranteed 
that  the  operations  performed  upon  him  by  the  Rus- 
sian bullets  were  aseptic  operations.  We  in  South 
Africa  had  reached  the  stage  of  antiseptics;  but  if 
one  recalls  the  attitude  of  our  military  authorities 
towards  the  most  rudimentary  and  obvious  hygienic 
precautions,  it  will  be  evident  that  something  much 
more  than  ordinary  military  daring  would  have 
been  required  of  the  surgeon  who  should  visit  the 
commanding  officer  with  the  proposal  to  give  the 
men  a  carbolised  bath  and  boiled  underclothing  pre- 
vious to  an  engagement;  more  especially  since  we 
have  it  on  the  highest  authority  that  "  medical  ad- 
vice is  a  good  thing  —  when  it  is  asked  for."  The 
Japanese  went  all  the  way,  applied  our  Listerism  as 
it  had  never  occurred  to  any  of  us,  for  all  I  know,  to 
practise  it,  and  as  it  certainly  would  not  have  been 
practised,  even  on  Lord  Lister's  own  recommenda- 
tion —  and  the  aseptic  bullets,  doing  their  funda- 
mentally dirty  work  in  at  any  rate  the  cleanest  way, 
piercing  sterile  clothing,  carrying  only  such  clothing 
into  the  wound,  or  leaving  only  such  clothing  in  con- 
tact with  the  edges  of  the  wound,  naturally  exacted 
the  lowest  death-rate  on  record  from  inflammation 
and  suppuration.  The  killing  power  of  the  modern 
bullet,  under  such  conditions,  is  very  small,  and 
ranges  little  beyond  the  area  of  the  brain  and  the 
heart,  whilst  wounds  even  of  these  organs  may  be 
recovered  from.     Not  until  the  rifle  bullet  —  itself, 


LISTERISM  AND  WAR  187 

as  we  have  seen,  a  sterilised  instrument  —  was  al- 
lowed to  perform  its  operations  under  substantially 
aseptic  conditions  could  we  discover  the  body's 
amazing  power  to  survive  uncomplicated  wounding. 
After  all,  it  might  be  argued  that,  except  on  the 
score  of  haemorrhage,  a  rifle  bullet  can  scarcely  ap- 
proach a  major  operation  of  to-day  in  the  extent  of 
its  injury  to  the  tissues;  and  as  for  the  haemorrhage, 
the  surgeon  is  at  hand  for  that. 

Evident  though  the  importance  of  such  aseptic 
technique  in  fighting  must  be,  the  ravages  committed 
by  typhoid  and  dysentery  are  more  important  still. 
To  the  general  this  may  not  seem  clear,  for  he  meas- 
ures his  success  by  the  issue  of  battles,  by  the  gain 
or  loss  of  positions  and  forts.  But  to  the  nation 
which  is  fighting  behind  the  general,  and  to  the  on- 
looker, it  is  evident  that  if  typhoid  kills  a  thousand 
men,  it  is  the  same,  in  the  long  run,  as  if  the  enemy's 
bullets  had  killed  them;  for,  as  was  conspicuously 
illustrated  by  the  Russo-Japanese  War,  we  are  reck- 
oning, in  most  campaigns,  with  the  pressure  of  popu- 
lation as  the  ultimate  driving  force.  The  greater 
part  of  war,  including  the  wars  supposed  to  be  re- 
ligious, is  a  phenomenon  of  the  expansion  of  races. 
There  is  a  law  of  population-pressure  which  is  strictly 
analogous  to  the  law  of  gaseous  pressure;  and  the 
pressure  of  population  is  the  irresistible  force  of  his- 
tory. Now  directly  we  conceive  of  war  thus  in 
biological  terms  we  shall  perceive  that  the  soldier's 
problem  is  at  least  as  much  to  save  life  as  to  destroy 
it.  It  is  the  pressure  of  population  that  must  win 
in  the  long  run,  to  whomsoever  the  glories  of  any 


1 88  SURGERY  AND  SOCIETY 

campaign  may  go :  and  a  Napoleon,  carrying  the  flag 
of  France  everywhere,  may  so  lower  her  population- 
pressure  as  to  prove  her  ruin  in  the  long  run ;  which 
things  we  now  see.  Thus  it  is  arguable  that  the 
really  successful  general  of  the  future  will  be  not  so 
much  the  clever  strategist  or  brave  fighter  as  the 
assiduous  champion  of  maternal  education  and 
health-visiting,  keeping  babies  alive,  which  is  the 
only  fashion  in  which  the  real  battles  of  nations  are 
won. 

The  digression  may  be  pardoned  if  it  serves  to 
make  clear  the  vast  importance  to  Japan  of  the 
means  whereby  she  kept  down  the  typhoid  and  dysen- 
tery death-rates  in  her  great  campaign.  Space  does 
not  avail  for  detailed  discussion  of  the  argument; 
but  it  is  a  curious  reflection  that,  whilst  the  French 
were  sneering  at  the  "  yellow  monkeys/'  the  greatest 
Frenchman  of  all  time*  was  winning  their  war  for 
them  —  as  he  might  have  won  the  Franco-Prussian 
War,  had  his  countrymen  had  the  wisdom  of  the 
"  yellow  monkeys  "  in  their  own  case. 

It  may  be  that  some  day  the  soldiers  and  sailors 
of  Great  Britain  will  be  engaged  again  in  a  great 
war,  perhaps  for  something  not  much  less  than  her 
national  existence.  Contemplating  such  a  possibil- 
ity, and  holding  the  estimate  already  made  of  the 
importance  of  the  hygienic  factor  in  modern  war,  I 
am  evidently  bound  to  consider  the  means  whereby 
we  may  be  enabled  to  do  for  ourselves  what  the 
Japanese  did  in  their  need. 

It  has  been  already  hinted  that,  by  a  curious 
paradox,  the  very  superstition  of  the  Japanese  en- 


LISTERISM  AND  WAR  189 

abled  them  to  avail  themselves  of  the  service  of 
science.  Their  duty  was  to  obey  the  Emperor,  the 
representative  of  Heaven,  and  his  representatives; 
and  if  they  were  instructed  in  the  demands  of  the 
technique  of  aseptic  surgery,  or  if  they  were  asked 
to  pray  or  to  burn  incense,  they  faithfully  did  so. 
They  were  substantially  aided  also  by  their  national 
inclination  towards  cleanliness.  Now  it  is  plain  that 
our  problem  is  a  different  and  a  much  more  difficult 
one  than  that  of  the  Japanese  authorities.  Let  us 
assume  for  the  moment  that  we  shall  have  men  in 
command  who  realise  the  importance  of  these  things 
and  know  what  should  be  done.  They  cannot  ap- 
peal to  superstition,  nor  is  the  desirable  practice 
merely  required  as  an  amplification  of  the  men's  ex- 
isting customs.  They  have  no  choice  but  to  appeal 
to  the  men's  intellects.  We  are  told  that  one  of  the 
disastrous  facts  in  South  Africa  was  that  the  men 
simply  refused  to  believe  in  the  wisdom  of  the  most 
elementary  sanitary  precautions.  They  did  not  care 
what  they  drank,  nor  where  they  bathed;  they  could 
not  be  persuaded  to  keep  milk  and  other  food  cov- 
ered, if  it  was  any  trouble  to  do  so,  though  typhoid 
was  raging  and  flies  ubiquitous,  carrying  the  infec- 
tion to  every  accessible  kind  of  food  —  including, 
of  course,  the  most  valuable  of  all  foods,  which  is 
milk.  Thus  the  few  doctors,  who  alone  were  pos- 
sessed of  the  life-saving  knowledge  amongst  all  that 
host,  had  to  fight  against  both  the  confident  ar- 
rogance of  the  officers,  and  the  careless  scepticism  of 
the  men.  Hence  the  ghastly  roll  of  preventable 
deaths  in  the  most  hideous  of  campaigns. 


igo  SURGERY  AND  SOCIETY 

There  is  nothing  for  it,  plainly,  but  the  staggering 
suggestion  that  we  set  to  and  make  ourselves  an 
educated  people.  Knowledge  was  always  power, 
but  it  is  vastly  more  powerful  nowadays  as  it  is 
vastly  extended  knowledge:  and  where  sufficient 
numbers  go  with  sufficient  knowledge,  there  victory 
will  be.  As  for  numbers,  we  in  Great  Britain  are 
hopelessly,  markedly,  and  inevitably  outstripped  by 
Germany.  It  is  part  of  natural  necessity  and  must 
be  so.  For  our  national  survival  we  need  knowl- 
edge above  all  things :  it  has  been  the  making  of 
modern  Germany,  and  has  not  yet  ended  its  career 
of  conquest  for  her.  We  must  have  the  elements  of 
the  laws  of  life  and  death  taught  in  our  schools;  I  see 
nothing  else  for  it,  even  if  the  demos  of  to-morrow 
is  to  be  a  trifle  uncertain  about  the  sequence  of  Henry 
VIII's  wives,  or  the  rights  and  wrongs  of  the  Hun- 
dred Years'  War  —  whatever  that  was.  In  the 
coming  time  we  simply  cannot  afford  to  have  an 
educated  class,  so-called,  providing  the  officers  for 
our  Services,  to  whom  chemistry  is  "  stinks,"  and 
bacteriology  "  bugs,"  and  Lord  Lister  a  "  saw- 
bones." The  hour  comes  when  it  is  a  matter  of  life 
and  death  whether  these  men  know  what  Listerism 
means,  and  then  they  fail  us;  and  of  what  use  are 
their  good  looks,  and  their  easy  manners,  and  their 
courage?  But  we  go  merrily  on,  supposing  that  we 
are  the  "  boys  of  the  bull-dog  breed,"  that  one  Eng- 
lishman is  worth  three  Frenchmen,  and  so  forth, 
whereas  the  question  at  issue  may  be,  which  side 
uses  the  best  filters?  It  would  be  absurd  to  decry 
courage  and  breeding  and  tradition:  but  would  it 


LISTERISM  AND  WAR  191 

be  more  absurd  than  to  decry  or  ignore  science,  as 
our  courage  and  breeding  and  tradition  still  do  to- 
day? 

It  is  in  matters  of  medical  science  that  our  popu- 
lar knowledge  is  especially  behind  the  times.  Such 
modern  inventions  as  the  motor-car  have  not  only 
served  to  instruct  large  numbers  of  the  population 
in  some  of  the  elements  of  mechanics  and  chemistry 
and  electricity,  but  they  have  sufficed  to  teach  the 
people  at  large  that  these  sciences  really  exist,  and 
that  their  students  certainly  must  be  consulted  and 
obeyed  when  occasion  arises.  But  the  medical 
sciences,  which  are  even  more  important  in  modern 
war  than  mathematics  or  electricity  or  mechanics, 
have  enjoyed  no  such  advantages;  and  the  tragic 
circumstance  is  that  they  are  almost  wholly  in  the 
keeping  of  a  great  and  highly  organised  profession, 
jealous,  conservative,  standing  upon  the  ancient 
ways,  dominated  by  the  interest  of  the  majority 
within  itself,  as  all  professions  tend  to  be.  The 
doctor  sets  out  to  be  and  undertakes  and  tries  to  be 
anything  but  a  doctor,  which  is  to  say,  a  teacher. 
The  rather  does  he  cultivate  a  professional  manner 
and  a  professional  jargon,  designed  to  soothe  and 
impress  rather  than  instruct  the  public;  and  an  an- 
cient language,  illegibly  written,  in  which  to  write 
his  prescriptions.  The  doctor  who  would  become 
a  real  doctor,  otherwise  than  as  a  teacher  of  medical 
students,  is  looked  upon  with  suspicion  or  contempt, 
it  is  hinted  that  he  is  little  better  than  a  charlatan, 
and  if  he  has  any  design  of  practising  his  profession 
he  will  find  that  he  is  either  gagged  or  discredited 


192  SURGERY  AND  SOCIETY 

or  boycotted.  In  order  to  speak  freely  he  must 
cease  to  practise,  as  the  present  writer  did  many 
years  ago,  and  even  then  let  him  beware  of  attain- 
ing or  appearing  to  attain  any  measure  of  success, 
if  he  would  escape  censure. 

None  of  this  is  at  it  should  be,  and  it  is  doomed, 
lock,  stock  and  barrel.  There  is  rising  up  a  new 
kind  of  doctor,  who  is  indeed  a  doctor.  He  is  not 
allowed  to  undertake  general  practice,  and  so  is 
practically  exempt  from  the  paralysing  pettinesses 
and  anti-social  vagaries  of  professional  etiquette  or 
medical  ethics,  fantastically  so-called.  He  is  the 
Medical  Officer  of  Health,  prefiguring  the  future, 
when  practically  the  whole  of  the  efforts  of  the 
medical  profession,  so  far  as  gross  disease  is  con- 
cerned, will  be  devoted  to  its  prevention;  and  when 
the  general  practitioner  will  be  chiefly  a  consulting 
psychologist,  as  was  suggested  by  myself  nearly  a 
decade  ago,  and  as  we  are  actually  beginning  to  see 
already  in  the  United  States  of  America.  Mean- 
while the  general  practitioner  of  to-day  finds  himself 
yearly  in  harder  straits,  and  there  is  indeed  no  hope 
for  him  except  by  such  a  mutation  or  change  of  type 
as  I  have  suggested. 

And  slowly  but  certainly  the  profession  and  the 
public  alike  will  grow  accustomed  to  what  is  still 
a  startling  novelty  and  something,  it  appears,  of  an 
anomaly  —  the  doctor  who  is  really  a  doctor.  The 
public  is  only  partly  to  blame  —  though  it  is  partly 
to  blame  —  for  its  present  appalling  lack  of  knowl- 
edge in  the  elements  of  hygiene  and  medicine.  The 
profession,   as  has  been  hinted,   is  also  to  blame; 


LISTERISM  AND  WAR  193 

and  the  time  is  at  hand  when  the  General  Medical 
Council,  in  especial,  will  have  to  consider  what  at- 
titude it  should  adopt  towards  the  man  who  desires 
to  spend  part  of  his  time  in  teaching  the  public  by 
his  voice  or  his  pen,  or  both,  yet  who  does  not  de- 
sire to  be  completely  cut  off  from  any  practice  of 
his  own.  At  present,  judging  by  the  only  case  known 
to  me,  and  as  far  as  I  know  the  first  case  of  the 
kind,  which  happens  to  be  my  own,  the  would-be 
doctor  must  abandon  all  practice,  or  his  professional 
"  brethren  "  will  accuse  him  of  advertising  and  he 
will  get  into  trouble.  Now  it  may  be  economically 
risky  to  cease  practice,  and  it  may  be  a  disadvantage 
to  the  teacher,  as  when  a  doctor,  after  a  lecture  of 
mine  on  alcohol,  sought  to  discredit  my  condemna- 
tion of  that  compound  on  the  ground  that  it  was 
some  time  since  I  had  been  in  practice. 

All  this  may  appear  to  the  reader  to  be  a  digres- 
sion, and  a  quite  irrelevant  one.  But  it  is  not  so. 
The  whole  purpose  of  my  book  is  didactic  and  none 
other.  It  is  written  to  instruct  the  public,  a  func- 
tion for  which  I  make  bold  to  claim  high  honour 
and  the  utmost  utility.  This  instruction  is  hitherto 
ludicrously  inadequate  in  quantity  and  in  quality  — 
a  remark  which  gives  an  obvious  opening  to  the 
critic  —  but  it  cannot  long  remain  so  if  we  are  to 
maintain  our  national  place  in  the  world.  From  the 
problems  of  modern  wars,  and  certain  recent  illus- 
trations —  astounding,  as  I  think  —  with  which  it 
furnishes  us,  I  have  sought  to  prove  that  public  opin- 
ion must  be  educated  and  instructed  in  these  matters 
until    it   reaches   the    status    of   public   knowledge. 


194  SURGERY  AND  SOCIETY 

That  end  can  be  satisfactorily  attained  only  through 
the  co-operation  of  those  who  alone  are  at  present 
possessed  of  the  knowledge  in  question,  namely,  the 
doctors;  and  that  is  my  reason  for  discussing  the 
means  whereby  doctors  may  be  made  doctors,  and 
the  difficulties  which  at  present  lie  in  the  way.  The 
people  perish,  or  will  perish,  for  lack  of  knowledge : 
which  end  may  this  book,  in  however  small  a  degree, 
serve  to  avert. 


CHAPTER  X 

SURGERY  AS  IT  IS 

In  the  present  chapter  we  may  attempt  to  survey 
the  science  and  art  of  surgery  as  it  is  to-day,  after 
the  revolution.  But  in  the  first  place,  we  shall  do 
well  to  contrast  the  theatres  of  the  past  with  those 
in  which  the  surgeon  of  to-day  chooses  to  work. 
The  contrast  is  of  practical  importance,  for  it  may 
lead  us  to  conclude  that  a  private  house,  even  if  it  be 
a  palace,  can  never  be  the  place  of  choice  for  a  sur- 
gical operation. 

The  surgery  of  the  past,  with  its  large  theatres, 
in  which  several  hundreds  of  spectators  could  watch, 
or  suppose  that  they  were  watching,  an  operation, 
has  gone  forever.  If  there  is  any  fashion  in  which 
the  modern  surgeon  can  afford  to  be  spectacular  it  is 
with  the  aid  of  the  cinematograph.  By  this  means 
M.  Doyen,  the  well-known  surgeon  of  Paris,  whose 
skill  in  operating  is  certainly  no  less  exceptional  than 
his  skill  in  drawing  attention  to  it,  was  able  to  dem- 
onstrate the  rapidity  and  technique  of  some  of  his 
operations  before  a  critical  audience  in  Edinburgh 
some  years  ago,  and  I  believe  that  the  method  has 
since  been  adapted  to  more  useful  purposes.  But, 
apart  from  such  means,  the  surgeon  of  to-day  is  best 
content  when  he  has  no  spectators  at  all,  and  cer- 
tainly he  has  nothing  to  say  to  the  possibility  of 

195 


196  SURGERY  AND  SOCIETY 

having  his  patient  wheeled  into  a  room  occupied  by 
crowded  students  from  the  dissecting-rooms  and  the 
post-mortem  theatre.  Thus  the  large  theatre  which 
was  used  for  some  of  the  earliest  abdominal  opera- 
tions in  the  Royal  Infirmary  of  Edinburgh  in  Lord 
Lister's  day  is  now  used  for  the  holding  of  out-pa- 
tient cliniques,  and  its  place  is  taken  by  a  dozen  or 
more  new  theatres  which,  between  them,  have  cer- 
tainly less  area. 

The  surgical  theatre  of  to-day,  like  the  modern 
lying-in-room,  ought  to  be  built  for  its  own  purpose 
and  used  for  no  other.  It  cannot  be  used  for  opera- 
tions one  day  and  for  out-patients  the  next.  "  No 
admission  except  on  business  "  must  be  its  motto. 
This  is  holy  ground,  to  be  trodden  only  for  pur- 
poses of  worship  and  never  by  the  soiled  foot.  It 
is  perfectly  certain  that,  though  the  surfaces  of  in- 
animate objects  are,  more  often  than  not,  covered 
only  with  innocent  microbes,  our  own  persons  and 
clothes  always  carry  microbes  which,  whilst  innocu- 
ous to  ourselves  or  to  others  under  ordinary  condi- 
tions, are  capable  of  causing  disaster  in  a  wound. 
Thus  everyone  who  enters  a  surgical  theatre  is  a 
source  of  possible  danger  to  present  or  future  pa- 
tients unless  he  takes  special  precautions,  and  the 
modern  surgeon  insists,  most  rightly,  on  those  pre- 
cautions being  taken.  The  casual  boot  must  no 
more  enter  the  temple  of  this  sane  and  scientific  cult 
than  the  mosque  of  the  Mohammedans.  Welling- 
ton boots,  capable  of  free  external  disinfection,  and 
never  permitted  to  leave  the  theatre,  must  be  donned 
by   the   surgeon   or   the   visitor:   not   that   we   can 


SURGERY  AS  IT  IS  197 

demonstrate  such  precautions  to  be  necessary,  but 
because  it  is  evidently  our  duty  to  take  them  until 
they  have  been  demonstrated  to  be  unnecessary. 
This  comparatively  trivial  point  may  be  placed  in 
the  forefront  of  our  statement  because  of  its  sugges- 
tive parallel  to  the  religious  practices  of  the  past. 
A  surgical  theatre  is  a  sacred  place,  dedicated  to  the 
cause  of  Life,  clean  in  no  ordinary  sense,  and  not 
to  be  profaned.  The  visitor  should  enter  it  with 
a  hushed  sense  of  responsibility  and  of  privilege,  if 
not  of  actual  worship,  or  he  is  impenetrable  to  the 
spirit  of  the  place. 

Let  us  consider  another  point,  which  is  of  much 
greater  importance.  In  the  beginning,  as  we  may 
recall,  Lister  employed  a  carbolic  spray,  designed  to 
kill  the  microbes  in  the  air  surrounding  the  opera- 
tion wound.  That  spray  was  an  annoyance  to  the 
surgeon,  and  its  contents  injurious  to  the  tissues  of 
the  patient,  and  better  results  have  been  obtained 
without  it.  But  this  is  not  to  say  that  Lister's  aim 
is  not  recognised  nor  sought  to  be  realised,  by  far 
more  efficient  and  aseptic  means,  in  our  own  day. 
For  in  the  first  place,  all  the  air  which  enters  a 
modern  theatre  of  the  best  type  is  first  filtered  by 
passage  through  suspended  fibres  down  which  water 
is  constantly  dripping,  and  this  filtered  air,  after  be- 
ing suitably  warmed,  is  forcibly  driven  into  the  thea- 
tre by  what  is  called  the  plenum  system  of  ventila- 
tion. No  casual  air  is  allowed  to  enter,  but  only 
that  which  has  been  filtered,  warmed  and  moistened. 
This  arrangement  naturally  goes  some  way  towards 
achieving  the  end  for  which  Lister  designed  his  car- 


iq8  SURGERY  AND  SOCIETY 

bolic  spray,  and  does  so  in  a  far  more  satisfactory- 
way.  The  remaining  risk,  so  far  as  the  air  is  con- 
cerned, is  now  derived  solely  from  the  persons  who 
enter  the  theatre;  and  in  this  respect,  also,  appro- 
priate precautions  are  taken.  Thus  it  may  be  care- 
fully arranged  that,  if  seats  be  built  for,  say,  half  a 
dozen  spectators,  they  shall  be  so  placed  that  the 
pure,  incoming  air  shall  flow  first  past  the  patient 
and  then  past  them  on  its  way  out.  They  may  take 
their  chances  —  which  is  really  no  chance  worth  nam- 
ing —  of  infection  from  the  patient,  but  they  can- 
not injure  him,  for  no  microbes  leaving  their  clothes 
or  breath  could  "  swim  up-stream,"  so  to  speak,  and 
reach  the  operating-table.  Again,  it  is  rigorously 
decreed  that  no  one  shall  come  to  the  theatre  from 
dissecting-room,  post-mortem  room,  infectious  fever 
wards,  or  attendance  upon  any  infection;  and  the 
spectators  enter  and  leave  by  a  special  door,  close 
to  their  appointed  seats,  so  that  the  risk  of  their 
affecting  the  patient's  chances  in  any  degree  at  all  is 
wholly  excluded. 

But  the  air  around  the  wound  might  be  infected 
from  the  clothes  or  the  breath  of  the  surgeon  himself 
or  his  assistants,  and  especially  is  there  some  risk 
to  be  apprehended  from  the  hair  and  the  breath. 
Therefore  those  who  are  really  to  surround  the  pa- 
tient must  wear  sterilised  blouses  and  aprons  and 
caps,  not  to  mention  their  boots;  they  should  for 
preference  be  clean-shaven;  and  all-embracing  steril- 
ised caps  will  be  used  so  as  completely  to  cover  their 
hair.  In  some  cases  a  type  of  costume  is  worn 
which  leaves  nothing  but  the  eyes  exposed,  but  if 


SURGERY  AS  IT  IS  199 

not,  the  surgeon  nowadays  usually  wears  some  kind 
of  respirator  over  the  mouth,  not,  as  in  the  usual 
case,  to  prevent  microbes  from  entering,  but  to  pre- 
vent them  from  emerging.  Possibly  microbes  never 
leave  the  mouth  and  nose  in  ordinary  breathing,  but 
they  certainly  do  so  in  coughing,  and  in  the  mouth- 
spray  which  accompanies,  to  some  extent,  even  the 
least  explosive  speech.  Thus,  if  we  are  inclined  to 
laugh  at  the  carbolic  spray,  or  label  it  superfluous, 
let  us  remember  that,  under  modern  conditions,  we 
recognise  the  principle  of  the  spray,  and  achieve  its 
aim  on  aseptic  lines,  by  Alteration  of  the  air  entering 
the  theatre,  by  eliminating  the  risk  of  the  spectator, 
and  by  covering  the  clothes,  hair  and  mouths  of 
those  who  surround  the  patient,  so  that  the  air  which 
is  in  contact  with  the  wound  is  practically  sterile. 
Plainly,  if  aseptic  surgery  is  to  be  practised,  these 
precautions  regarding  the  air  are  necessary,  or  a 
consumptive  surgeon  or  nurse,  to  take  only  one  in- 
stance of  many,  might  infect  the  wound  by  the  simple 
act  of  speech. 

Let  it  be  added  that  the  corners  and  edges  of  the 
theatre  are  rounded  and  smooth,  and  that  the  floor 
is  always  moist,  no  such  abomination  as  the  dry 
cleaning  practised  in  most  houses  being  thinkable 
for  a  moment,  that  walls,  floor  and  everything  else 
are  regularly  swilled  with  antiseptic  lotions,  and 
that  the  most  strenuous  precautions  are  taken  when- 
ever any  septic  case  has  had  to  be  dealt  with.  If  the 
surgeon  has  several  cases  to  deal  with  in  one  theatre 
on  one  occasion  he  will,  of  course,  take  first  the  cases 
of  "  unbroken  skin,"  and  last  those  which  actually 


200  SURGERY  AND  SOCIETY 

bring  infection  into  the  theatre.  Or  a  given  theatre 
may  be  entirely  given  up  to  non-septic  cases,  so  that 
no  infection  ever  enters  it  at  all. 

But  there  is  much  more  to  be  said  before  we  have 
done  justice  to  the  modern  surgical  theatre.  The 
lighting  arrangements  must  be  perfect,  alike  for  nat- 
ural and  for  artificial  light.  One  does  not  need  to  be 
a  surgeon  to  know  that  it  is  necessary  for  him  to  see, 
in  his  theatre,  by  day  or  by  night,  as  well  as  he 
possibly  can;  and  some  kind  of  portable  light  is  a 
necessity  for  special  purposes.  Then,  of  course, 
there  is  all  the  apparatus  for  the  sterilisation  of 
blouses,  caps,  aprons,  swabs,  instruments  and  so 
forth;  and  the  provision  for  the  sterilisation  of  the 
surgeon's  fingers,  the  water  being  turned  on  and  off 
by  pedals,  so  as  to  avoid  the  risk  involved  in  the 
turning  of  taps.  Glass  tables  on  rubber  castors,  and 
the  like,  will  be  a  convenience,  and  the  operating- 
table  must  be  of  the  right  height,  perfectly  washable, 
warmed  throughout,  and  susceptible  of  bending  in 
various  sections  or  angular  movements  as  a  whole. 

No  one  would  be  so  foolish  as  to  assert  that  failure 
will  follow  the  absence  of  these  precautions  and  this 
provision  in  every  case.  Successful  and  cleanly 
operations  have  been,  are  being,  and  will  be  per- 
formed, though  in  steadily  diminishing  numbers,  in 
private  houses,  in  conditions  which  defy  every  Lis- 
terian  canon,  on  the  battle-field,  in  the  dry  dock  or 
the  coal-mine,  or  amid  the  wreckage  of  a  train. 
Emergency  cases  will  always  occur,  oftenest  in  or- 
dinary houses,  but  also  in  many  other  places,  where 
the  surgeon  must  operate  on  the  spot  as  best  he  may, 


SURGERY  AS  IT  IS  201 

and  in  a  very  large  proportion  of  these  cases  he  will 
be  successful,  notwithstanding  the  conditions,  in 
performing  an  adequate  antiseptic  operation.  But 
the  conditions  which  have  been  described  in  the  fore- 
going pages,  and  which  are  illustrated  in,  for  in- 
stance, the  beautiful  twin  theatres  at  St.  Thomas's 
Hospital  in  London,  which  were  opened  by  Lord 
Lister  about  a  decade  ago  —  are  those  which  con- 
duce to  the  highest  measure  of  success;  and  no  one 
can  contemplate  them  without  realising  that,  in  this 
one  respect  alone,  the  public  provision  for  the  prac- 
tice of  Listerism  is  lamentably  inadequate,  but  not 
more  so  than  the  public  appreciation  of  it. 

Let  it  be  clearly  understood,  then,  that  a  bed- 
room, or  any  other  room  in  a  private  house,  is  no 
place  for  a  surgical  operation  —  though  perhaps  the 
best  of  modern  bath-rooms  are  not  very  far  from  the 
ideal.  This  is  no  less  true  than  that  the  ordinary 
bedroom  is  not  the  ideal  place,  from  a  Listerian 
point  of  view,  for  a  confinement.  If,  therefore, 
the  surgeon  considers  an  operation  advisable,  and  it 
is  possible  to  move  the  patient  so  as  to  have  it  per- 
formed in  a  theatre  built  and  kept  for  the  purpose, 
my  counsel  to  the  public  is  that  his  advice  and  wishes 
should  be  respected.  The  advantage  to  the  patient 
is  well  worth  the  extra  expense ;  and  one  of  the  lead- 
ing purposes  of  the  present  volume  will  have  been 
frustrated  if  I  have  not  succeeded  in  convincing  the 
reader  that  that  is  so. 

Here,  of  course,  the  demands  of  science  come  into 
conflict  with  modern  economic  conditions.  At  pres- 
ent,  the  navvy  who  is   carried  to  hospital  with   a 


202  SURGERY  AND  SOCIETY 

compound  fracture  can  immediately  avail  himself 
of  a  surgical  theatre  such  as  we  have  described,  and 
in  London  and  in  a  very  few  other  large  cities  there 
exist  surgical  homes  which  are  similarly  equipped, 
and  of  which  the  substantially  well-to-do  can  avail 
themselves.  But  there  are  not  enough  surgical  the- 
atres of  this  type  in  the  world  for  a  tenth  or  a  hun- 
dredth part  of  the  cases  which  really  should  be 
treated  in  them,  and  there  is  a  vast  and  most  im- 
portant section  of  the  community  which  has  not  the 
advantages  in  this  respect  which  are  shared  by  the 
wealthy  and  the  poor. 

No  plea  is  here  made  that  we  should  start  any 
philanthropic  enterprise  for  the  provision  of  modern 
surgical  theatres  everywhere.  All  the  available 
money  and  time  and  labour,  and  much  more,  are 
still  and  will  long  be  required  for  the  much  more 
profitable  task  of  removing  the  conditions  which  lead 
up  to  the  need  for  surgical  intervention  at  all.  Bet- 
ter than  building  theatres  is  the  abolition  of  the  need 
for  them.  But  the  present  state  of  things  is  highly 
anomalous,  and  for  the  nonce  one  may  leave  it  sim- 
ply stated  here,  hoping  to  have  insisted,  first,  that 
where  there  is  a  choice  between  operation  under 
ideal  conditions  or  operation  at  home,  we  should  be 
prepared  to  make  a  monetary  sacrifice  which  is  cer- 
tainly worth  while;  and  second,  that  there  is  room 
and  occasion  for  some  kind  of  common  provision 
amongst  the  class  still  unprovided  for  in  this  respect, 
possibly  by  means  of  insurance  against  the  need  of 
an  operation,  which  seems  to  me  to  be  a  very  sensi- 
ble precaution,  and  also  by  other  economic  devices 


SURGERY  AS  IT  IS  203 

which  were  better  left  to  the  suggestion  of  those 
more  competent  in  such  matters  than  the  present 
writer. 

We  may  now  proceed  to  survey  the  accomplish- 
ment of  surgery  to-day,  and  may  choose  a  repre- 
sentative case,  illustrating  the  kind  of  use  to  which 
such  theatres  as  have  been  described  may  be  put. 
When  the  conditions  for  asepsis  have  been  estab- 
lished, both  in  the  equipment  and  ventilation  of  the 
theatre,  and  in  the  technique  of  cleansing  the  pa- 
tient's skin  and  the  surgeon's  fingers,  he  is  entitled 
to  operate  upon  unbroken  skin  in  cases  where  neither 
life  nor  health  is  involved,  where  there  is  no  pain 
nor  injury  nor  defect  of  any  kind  threatening  to 
shorten  life,  and  where,  for  sufficient  reasons,  the 
surgeon  may  actually  make  four  compound  fractures 
at  one  operation.  These  cases  are  all  the  more  sig- 
nificant of  what  Listerism  has  achieved  if  we  re- 
member that  its  first  achievement  was  to  lower  the 
death-rate  after  amputation  for  compound  frac- 
ture. One  can  scarcely  believe  that  even  Lord  Lis- 
ter himself,  when  he  was  performing  those  ampu- 
tations and  saving  lives  which  would  otherwise  have 
been  lost,  could  have  guessed  that  in  less  than  thirty 
years  his  disciples  would  be  deliberating  laying  a 
child  upon  a  table  and  breaking  each  leg  in  two 
places  by  means  of  knife  and  chisel  and  saw.  We 
have  to  realise  the  formidable  character  of  inflam- 
mation occurring  in  bone,  the  very  great  risk  to  the 
limb,  and  the  substantial  risk  to  life,  more  especially 
in  young  patients,  in  order  to  realise  the  pitch  to 
which  aseptic  surgery  has  attained  when  four  com- 


204  SURGERY  AND  SOCIETY 

pound  fractures  may  be  produced  in  a  single  patient 
who  suffers  from  nothing  more  deadly  than  knock- 
knees. 

Of  course  there  should  be  no  such  thing  as  knock- 
knees,  for  they  are  the  consequences  of  rickets, 
which  is  an  entirely  preventable  disease  of  malnu- 
trition, and  even  on  the  rankest  grounds  of  economy 
it  would  be  cheaper  to  prevent  it  than  to  pay  for  its 
treatment  in  general  hospitals,  though  the  former 
would  be  called  "  socialism, "  which  Lord  Rosebery 
assures  us  is  "  the  end  of  religion,"  and  the  latter  is 
charity  and  therefore  religious.  But  whilst  think- 
ing of  this  highly  aristocratic  order  is  allowed  to 
control  our  national  policy,  there  will  be  plenty  of 
rickets  to  treat,  and  plenty  of  consequent  knock- 
knees.  These  are,  of  course,  a  deformity,  and  they 
very  considerably  subtract  from  the  stature.  But 
the  surgeon  intervenes,  guarded  by  his  perfect  tech- 
nique which  he  practises  in  a  theatre  such  as  we 
have  described  and,  having  cut  down  to  the  two 
thigh-bones  or  femora,  and  shin-bones  or  tibiae,  he 
breaks  all  four,  and  sets  them  so  as  to  produce 
straight  limbs.  The  patient  goes  back  to  bed  with 
his  compound  fractures  of  both  femora  and  tibiae, 
makes  an  uninterrupted  recovery,  with  no  pain 
worth  mentioning,  nor  fever,  nor  even  malaise,  and 
leaves  his  bed  straight-limbed  and  some  inches  taller 
than  when  he  took  to  it:  also  as  enthusiastic  as  ever 
about  Mr.  Chamberlain  or  President  Roosevelt,  and 
as  ignorant  of  the  name  or  the  existence  of  Lord 
Lister. 

This  case  is  in  some  ways  perhaps  as  striking  as 


SURGERY  AS  IT  IS  205 

any  that  can  be  named,  though  the  popular  notion 
of  the  distinction  between  "  vital  "  and  other  or- 
gans will  fail  to  appreciate  its  full  meaning.  It  is 
a  type  of  that  great  variety  of  cases  in  which  surgery 
finds  the  best  conditions  for  its  success.  No  mi- 
crobes are  present,  the  operation  can  be  performed 
so  as  to  ensure  that  none  are  introduced,  and  the 
problem  becomes,  for  practical  purposes,  a  purely 
mechanical  one.  Under  these  conditions  there  are 
practically  no  limits  to  what  the  surgeon  may  achieve, 
and  he  makes  further  advances  every  year.  But  I 
know  of  no  other  case  where  such  formidable  in- 
juries are  produced  without  being  demanded  in  the 
interests  of  life  or  health. 

Perhaps  more  striking,  to  those  who  do  not  know 
what  a  compound  fracture  under  ordinary  condi- 
tions means,  is  the  justifiable  freedom  with  which 
the  surgeon  now  opens  the  abdomen  for  purposes 
of  diagnosis  rather  than  anything  else.  A  "  diag- 
nostic incision  "  in  order  to  "  explore  the  abdomen," 
in  cases  where  the  surgeon  does  not  expect  to  do 
any  more,  is  a  matter  of  everyday  practice;  and 
since  most  of  us  know  what  peritonitis  means,  this 
may  serve  to  indicate  the  range  and  the  security  of 
modern  surgery,  as  also  the  remarkable  degree  to 
which  the  body  will  withstand  injuries,  provided 
that  it  gets  a  fair  chance,  and  is  not  asked  to  with- 
stand infection  also. 

The  peritoneum  is  the  lining  membrane  of  the 
abdominal  cavity,  and  is  reflected  upon  the  ab- 
dominal organs  so  as  to  constitute  an  external  coat 
for  them.     The  introduction  of  pathogenic  or  dis- 


206  SURGERY  AND  SOCIETY 

ease-producing  microbes  into  the  abdominal  cavity 
leads  to  peritonitis,  which  is  an  exceedingly  deadly 
form  of  inflammation,  being  even  more  so  in  men 
than  in  women.  This  introduction  may  occur  from 
without  or  from  within.  A  surgical,  a  homicidal 
or  an  accidental  wound  may  introduce  the  microbes 
from  without,  and  the  great  service  of  Listerism  to 
abdominal  surgery  consists  in  its  assurance  that  the 
Listerian  surgeon  may  confidently  open  the  abdo- 
men without  fear  that  he  will  set  up  peritonitis. 

But  much  the  greater  part  of  abdominal  surgery 
is  concerned  with  the  risk  of  peritonitis  being  set  up 
from  within.  The  surgeon  now  intervenes,  arrests 
or  removes  the  condition  which  is  threatening  to 
produce  peritonitis  and,  producing  no  peritonitis  on 
his  own  account,  is  able  to  save  the  patient's  life. 

The  nature  of  these  cases  will  be  clear  if  we 
consider  the  rudiments  of  abdominal  anatomy. 
Through  the  abdomen  there  runs  a  much-coiled  tube, 
of  which  the  stomach  is  the  most  capacious  portion. 
Anything  inside  this  tube  is,  in  a  sense,  outside  the 
body,  and  it  is  constantly  occupied,  in  point  of  fact, 
by  certain  microbes  which  could  not  be  tolerated 
anywhere  else.  If  they  pierce  the  wall  of  the  tube 
and  reach  the  peritoneum,  they  set  up  peritonitis, 
with  disastrous  results,  just  as  if  the  surgeon  or  an 
assailant  had  introduced  microbes  to  the  peritoneum 
from  without.  This  accident,  commonly  known  as 
perforation,  is  one  of  the  risks  of  typhoid  fever,  and 
it  not  infrequently  follows  from  the  existence  of 
ulceration  in  the  stomach.  In  the  latter  case  the 
surgeon  might  intervene  before  the  ulcer  gave  way, 


SURGERY  AS  IT  IS  207 

and  might  excise  It  altogether,  bringing  the  edges 
together,  and  so  cure  the  patient  at  a  stroke.  But 
the  commonest  cause  of  peritonitis  in  men  is  perfora- 
tion following  upon  inflammation  in  the  appendix, 
and  when  the  surgeon  operates  for  appendicitis  he 
does  so  in  order  to  prevent  an  imminent  and  very 
probably  fatal  peritonitis,  which  would  otherwise 
follow.  He  finds  the  appendix,  and  bodily  removes 
it,  brings  together  the  cut  edges  of  the  bowel,  and  so 
saves  the  peritoneum  and  the  patient. 

People  often  ask  why  we  hear  so  much  of  appen- 
dicitis nowadays,  and  how  it  is  that  our  ancestors 
did  not  suffer  from  it.  But  there  is  no  doubt  that 
they  did  suffer  from  it,  and  evidence  of  its  occur- 
rence has  been  found  in  an  Egyptian  mummy.  But 
before  surgery  dared  to  intervene,  appendicitis  very 
commonly  developed  into  peritonitis,  usually  fatal; 
and  it  may  roughly  be  said  that  we  nowadays  hear 
about  appendicitis  just  in  proportion  as  our  ancestors 
used  to  hear  about  peritonitis.  Nowadays  the  sur- 
geon intervenes,  prevents  infection  of  the  perito- 
neum, and  in  many  thousands  of  cases  every  year 
saves  the  patient's  life.  In  Great  Britain  there  are 
now  about  fifteen  thousand  operations  for  appendi- 
citis performed  yearly,  and  it  is  not  an  unreasonable 
estimate  that  in  two-thirds  of  these  the  result  is  to 
save  life. 

The  procedure  of  operation  for  appendicitis  has 
been  grossly  abused  in  some  hands.  So  have  the 
tenets  of  Christianity,  to  take  no  other  instance.  To 
condemn  surgeons  and  surgery  in  the  one  case  would 
be  no  more  justifiable  than  to  condemn  religion  in 


208  SURGERY  AND  SOCIETY 

the  other.  To  this  subject  we  shall  return.  Mean- 
while let  us  note  that  there  are  two  distinct  conditions 
in  which  surgery  may  propose  to  operate  for  appen- 
dicitis. He  may  do  so  because  it  is  evident  that 
otherwise  the  patient,  evidently  suffering  from  acute 
poisoning,  will  die.  But  he  may  also  do  so  when 
the  patient  is  perfectly  well,  and  in  no  immediate 
danger  of  any  kind.  The  propriety  of  this  pro- 
cedure is  one  which  necessarily  comes  up  before  the 
layman  very  frequently,  and  it  may  carefully  be  con- 
sidered here,  none  the  less  because  it  has  been  so 
often  abused. 

Appendicitis  is  a  disease  of  somewhat  obscure 
origin,  but  is  beyond  all  question  the  result  of  an 
infection.  The  microbes  which  do  the  harm  may 
be  of  recent  and  exceptional  introduction  into  the 
body,  as  most  of  us  would  take  for  granted,  or  they 
may  be  a  vicious  development  of  microbes  which 
normally  inhabit  the  bowel  without  harm ;  and,  if  so, 
we  have  yet  to  learn  the  cause  of  the  change  in  their 
behaviour.  However  that  may  be,  the  malady  is 
an  infection  and,  after  recovery  from  it,  the  patient 
is  presumably  in  some  way  altered  in  consequence  of 
the  chemical  processes  which  were  involved  in  the 
disease.  In  a  large  number  of  infections,  as  we 
know,  the  subsequent  change  in  the  patient  is  such 
that  he  can  scarcely  be  infected  in  that  fashion  again. 
He  has  acquired  an  immunity  which  may  be  lifelong 
or  last  for  some  years,  but  which  is  very  real  and 
very  satisfactory. 

But  in  a  large  number  of  other  infections  no  such 
result  obtains  as  in  the  case  of  small-pox  or  scarlet 


SURGERY  AS  IT  IS  209 

fever.  In  the  various  infections  of  the  respiratory 
tract,  such  as  pneumonia,  pulmonary  consumption 
and  influenza,  all  the  evidence  suggests  that  each  at- 
tack renders  the  patient  not  less  liable  but  more 
liable  to  another.  Why  these  profound  differences 
between  apparently  parallel  processes  should  exist 
we  cannot  say,  but  the  fact  is  unquestionable.  Un- 
fortunately the  surgical  infections  in  general  appear 
to  confer  no  immunity  and,  so  far  as  appendicitis  is 
concerned,  it  is  exceedingly  probable  that  the  patient 
who  has  recovered  from  one  attack  will  have  an- 
other. Further,  the  attacks  are  liable  to  become 
more  severe ;  and  the  operative  procedure  which  may 
be  required  sooner  or  later  will  become  progressively 
more  difficult  as  the  number  of  previous  attacks  in- 
creases, for  they  involve  local  injury,  displacement 
and  complications  which  present  to  the  surgeon  a 
problem  which  may  be  insoluble  and  is  certainly  very 
different  from  that  involved  in  removing  a  practi- 
cally normal  appendix. 

On  these  grounds  it  will  surely  be  clear  that,  if 
a  patient's  general  constitution  be  satisfactory,  and 
if  the  surgeon  can  be  assured  of  the  safety  of  his 
aseptic  precautions,  it  may  be  well  worth  the  pa- 
tient's while  to  be  rid  of  the  appendix  once  and  for 
all,  even  though  it  is  always  possible  that  the  appen- 
dix may  never  be  going  to  give  any  trouble  again. 
Much  more  urgent  are  the  indications  for  this  pro- 
cedure in  cases  where  a  young  man  is  about  to  go 
abroad  pioneering,  or  where  a  young  woman  is  about 
to  be  married. 

The  surgeon  lives  mainly  on  the  fees  he  obtains 


2io  SURGERY  AND  SOCIETY 

for  operating,  and  thus,  if  for  no  other  reason,  he 
has  a  bias  in  favour  of  recommending  an  operation 
whenever  he  can.  Thus  this  particular  operation 
may  be,  and  often  has  been,  performed  when  there 
was  no  adequate  reason  for  it.  It  has  been  per- 
formed, also,  by  incompetent  or  unlucky  men  who 
have  not  succeeded  in  finding  the  appendix  at  all, 
but  have  held  their  tongues,  and  the  subsequent  oc- 
currence of  appendicitis  in  the  patient  who  naturally 
supposed  that  he  did  not  possess  an  appendix  has 
been  highly  discreditable  to  surgery.  The  plain  les- 
son to  be  drawn  is  that,  as  in  all  other  circumstances, 
exigencies  and  needs,  one  should  have  to  do  with 
responsible,  competent  and  honourable  people. 
This  necessity  is  not  peculiar  to  surgery;  it  is  just  the 
same  if  one  desires  to  get  married  or  make  a  will  or 
a  friend. 

When  the  conditions  are  satisfied  it  may  very  well 
be  that  an  operation  is  recommended.  The  appen- 
dix is  removed,  without  any  risk  worth  naming,  and 
the  risk  its  presence  involved  is  removed  forever. 

Nor  is  this  by  any  means  the  only  case  in  which 
the  surgeon  nowadays  opens  the  abdomen  without 
anything  like  absolute  compulsion.  The  procedure 
is  so  safe  and  simple  that  it  may  be  undertaken  for 
any  purpose  which  requires  it.  Thus,  for  instance, 
it  may  happen  that  a  kidney,  which  should  rightly 
be  fixed  in  its  position  by  means  of  a  firm  envelope 
of  fat,  becomes  movable  or,  as  the  inaccurate  ex- 
pression goes,  "  floating."  No  risk  to  life  is  in- 
volved in  this  condition,  but  it  appears  sometimes 
to  \ft  a  catfcfe  of  nervous  symptoms  of  various  kinds, 


SURGERY  AS  IT  IS  211 

and  of  some  pain.  Here  the  surgeon  is  quite  at 
liberty  to  open  the  abdomen  and  stitch  the  errant 
kidney  to  the  fibrous  membrane  covering  the  last 
rib,  so  that  it  can  wander  no  more.  The  risk  of 
such  a  procedure  in  anything  like  competent  hands 
is  probably  much  less  than  that  of,  say,  engaging  a 
taxi-cab  for  a  journey  in  London. 

The  degree  of  merely  mechanical  injury  which 
the  body  will  tolerate  is  quite  amazing.  The  intro- 
duction or  manufacture  of  poisons  in  it  is  a  very 
different  matter,  but  that  is  precisely  what  modern 
surgery  avoids.  If  certain  other  conditions,  by  no 
means  impossible,  are  complied  with,  the  surgeon 
may  practically  do  anything  he  likes.  The  special 
risk  of  extensive  abdominal  procedures  lies  in  what 
is  called  "  surgical  shock,"  but  that  is  a  condition 
which  becomes  rarer  and  rarer  as  surgeons  improve 
the  details  of  their  technique.  If  the  patient  is  kept 
properly  warmed  throughout  the  operation,  if  he  is 
kept  unconscious  by  means  of  a  minimal  but  constant 
quantity  of  a  pure  anaesthetic,  for  the  inhalation  of 
which  he  has  been  carefully  prepared  in  the  matter 
of  diet  and  so  forth,  and  if  the  operation  be  con- 
ducted on  aseptic  lines,  so  that  his  body  is  not  com- 
pelled to  absorb  considerable  quantities  of  powerful 
poisons  like  carbolic  acid  and  perchloride  of  mercury 
— "  surgical  shock  "  will  be  very  rarely,  indeed,  ob- 
served when  he  gets  back  to  bed.  Under  these  con- 
ditions the  abdomen  will  tolerate,  for  instance,  the 
removal  of  eleven  feet  or  more  of  the  bowel,  the 
removal  of  the  entire  stomach,  and  a  host  of  other 
operations  of  which  these  give  a  fair  indication.     In 


212  SURGERY  AND  SOCIETY 

what  is  called  Caesarean  section  the  obstetric  surgeon 
demonstrates  the  highest  possibilities  of  abdominal 
surgery,  and  nothing  more  triumphant  could  well  be 
imagined. 

Abdominal  surgery  is  now  a  commonplace,  and  it 
does  not  strike  us  as  remarkable.  It  is  true  that  the 
abdomen  does  not  contain  vital  organs  in  the  same 
sense  as  the  chest  and  head,  and  it  is  true  also  that 
the  surgery  of  these  parts  of  the  body  is  of  later 
development,  and  thus  has  attracted  more  attention 
of  late  years.  But  however  great  the  skill  which 
the  surgeon  develops  in  dealing  with  the  needs  of 
the  chest  and  head,  he  can  never  find  in  these  any 
such  field  as  the  abdomen  offers  him,  and  we  cannot 
doubt  that,  apart  from  the  sphere  of  obstetrics,  the 
chief  services  of  Listerism  to  mankind  are  summed 
up  in  the  phrase,  abdominal  surgery. 

Conspicuous  illustrations  are  furnished  by  those 
not  infrequent  maladies  which,  whilst  long  com- 
patible with  life,  are  without  doubt  the  most  painful 
to  which  we  are  ever  exposed.  If  any  mechanical 
obstacle  sticks  in  one  of  those  tubes  of  the  body 
which  are  lined  with  unstriped  muscular  fibres,  the 
consequent  efforts  of  those  fibres  to  dislodge  the  ob- 
stacle tend  to  assume  an  acutely  spasmodic  form, 
giving  rise  to  attacks  of  what  is  called  colic.  Such 
mechanical  obstacles  not  infrequently  occur  in  rela- 
tion to  the  secretion  of  the  liver  and  that  of  the 
kidney,  giving  rise  to  what  is  called  hepatic  colic  in 
the  first  case  and  renal  colic  in  the  second.  Other 
symptoms  besides  the  pain  occur  in  such  cases,  and 
these  may  sometimes  be  of  grave  import,  but  the 


SURGERY  AS  IT  IS  213 

appalling  and  unparalleled  pain  is  the  leading  fea- 
ture of  such  cases.  The  obstacle  in  question  is  a 
solid  mineral  body,  formed  in  one  fashion  or  an- 
other by  precipitation  of  certain  mineral  salts  which 
should  normally  remain  in  solution  and  thus  pass 
along  the  ducts  without  difficulty.  In  these  cases  of 
gall-stone  or  stone  in  the  kidney  the  resources  of 
medicinal  treatment  are  very  commonly  inadequate. 
Powerful  sedative  drugs  may  somewhat  dull  the 
pain,  at  serious  cost  to  the  patient's  nervous  system; 
and  a  variety  of  drugs  and  diluent  fluids  may  be 
taken  in  the  hope  that  the  obstructing  stone  may 
be  redissolved  and  thus  dissipated.  But  the  pa- 
tient's plight  too  often  remains  pitiable. 

Here  Listerism  mercifully  and  triumphantly  in- 
tervenes. During  the  last  decade  it  has  been  sub- 
stantially aided,  so  far  as  diagnosis  is  concerned,  by 
the  use  of  the  Rontgen  rays,  which  will  frequently 
serve  to  demonstrate  and  locate  the  offending  stone. 
This  innovation  may  be  of  value  in  directing  the 
surgeon's  knife,  and  also  in  forbidding  its  employ- 
ment by  demonstrating  that  no  stone  is  present  in  a 
suspected  case.  Usually,  however,  there  is  no 
doubt.  The  surgeon,  fortified  by  his  Listerian 
technique,  cuts  freely  and  safely  down  upon  the  ob- 
structed duct,  whichever  it  may  be,  opens  it  where 
the  presence  of  the  stone  is  palpable  to  his  finger, 
removes  the  stone,  stitches  up  the  duct,  makes  good 
the  injury  done  in  reaching  it  and,  if  he  follows  the 
principles  of  my  humane  and  inspiring  teacher, 
Professor  John  Chiene,  will  show  the  stone  or  stones 
to   the    patient   on   the    following    day.     There    is 


2i4.  SURGERY  AND  SOCIETY 

scarcely  a  simpler,  more  satisfactory  or  more  dra- 
matic cure  to  be  obtained  in  the  whole  realm  of  the 
healing  art. 

More  recent  than  these  applications  of  Listerism 
to  the  abdomen  proper  is  the  advance  of  surgery  in 
the  lowest  section  of  the  body  cavity,  which  is  known 
as  the  pelvis  or  basin.  Progress  here  is  rapid  and 
recent.  When  I  was  a  student,  only  a  decade  ago, 
I  remember  another  student  suggesting  to  Professor 
Chiene  that  a  gland  called  the  prostate  might  possi- 
bly be  removed  in  order  to  relieve  the  injury  caused 
by  its  not  infrequent  enlargement.  The  reply  was 
that  such  an  operation  would  be  beyond  the  limits 
of  surgical  possibility.  But  it  is  now  performed 
almost  every  day,  and  total  excision  of  the  prostate 
has  been  the  boon  of  boons  to  many  hundreds  of 
elderly  men  during  the  last  few  years,  for  whom 
nothing  could  have  been  done  in  any  past  time. 

The  professing  Eugenist  cannot  but  make  special 
reference  to  other  possibilities  of  surgery  in  this  re- 
gion of  the  body.  There  are  not  a  few  cases  where 
the  principles  of  what  I  have  called  negative  eu- 
genics, defined  as  the  discouragement  of  parenthood 
on  the  part  of  the  unworthy,  seem  clearly  to  demand 
the  aid  of  surgery  for  their  due  realisation  without 
the  infliction  upon  the  individual  of  more  hardship 
than  the  present  state  of  public  opinion  would  be 
willing  to  countenance.  The  demand  in  such  cases 
is  for  what  is  commonly  called  sterilisation,  the  word 
being  used  in  a  sense  very  different  to  that  which  it 
bears  on  many  pages  of  the  present  volume.  Let  it 
be  clearly  understood  that  sterilisation  is  not  the  in- 


SURGERY  AS  IT  IS  215 

dicated  measure  for  the  majority,  or  even  for  so 
many  as  one-tenth,  of  those  who  should  come  under 
the  ban  of  negative  eugenics.  In  the  great  majority 
of  such  cases,  including  the  whole  company  of  the 
feeble-minded,  we  find  that  the  individual,  if  per- 
mitted to  remain  in  the  community,  injures  it  and 
is  injured  by  it,  quite  apart  from  any  eugenic  ques- 
tion. Such  persons  require  what  for  many  years  of 
public  propaganda  I  have  been  accustomed  to  call  by 
the  somewhat  ominous  name  of  segregation,  but 
what  I  now  call  "  permanent  protection,"  which 
means  precisely  the  same  thing,  but  states  it  in  a 
fashion  which  does  not  lead  the  foolish  critic  to  sup- 
pose that  we  are  recommending  something  punitive 
or  cruel.  Now  if  the  feeble-minded  or  other  per- 
sons who  come  under  the  ban  of  negative  eugenics 
be  permanently  cared  for  apart  from  the  rest  of  the 
community  —  and,  of  course,  under  conditions 
which  involve  the  separation  of  the  sexes  —  they  do 
not  require  to  be  sterilised. 

But  when  that  is  clearly  recognised  it  remains  true 
that,  in  not  a  few  cases,  ever  occurring,  sterilisation, 
and  nothing  else,  is  the  ideal  remedy  or  prophylactic 
for  the  future.  The  public  genius  for  getting  hold 
of  new  ideas  by  the  wrong  end  has  showed  itself  in 
this  instance  also,  and  sterilisation  has  been  pictured 
as  a  cruel  and  brutal  measure,  proposed  by  cold- 
blooded men  of  science  in  the  spirit  of  the  Inquisi- 
tion as  a  species  of  new-fangled  torture  to  be  inflicted 
upon  practically  every  unhappy  person  who  does  not 
come  up  to  their  eugenic  standard.  On  the  con- 
trary, I  propose  sterilisation  for  certain  cases  as  the 


2i6  SURGERY  AND  SOCIETY 

most  humane  measure  which  can  be  applied.  There 
are  not  a  few  instances  where,  in  coming  days,  the 
law  might  well  offer  to  the  individual  the  alternative 
between  some  form  of  seclusion  and  sterilisation. 
Now,  whilst  permanent  care  is  the  only  kind  and 
economical  way  of  dealing  with  the  feeble-minded, 
it  would  be,  of  course,  a  very  cruel  and  a  very  ex- 
pensive way  of  dealing  with  a  man  who  was  per- 
fectly able  to  look  after  himself  and  do  useful  work, 
but  the  possibility  of  parenthood  on  the  part  of 
whom  was  to  be  rigorously  excluded.  In  some  such 
cases  as  these  it  would  be  immediately  seen  that  ster- 
ilisation was  the  humane  way  of  meeting  the  social 
need.  So  far  as  the  future  is  concerned,  it  simply 
puts  an  end  to  the  individual;  so  far  as  the  present 
is  concerned,  it  effects  no  change  whatever;  and  that 
is  precisely  what  is  to  be  desired  in  the  cases  under 
consideration. 

By  sterilisation  I  mean  no  operation  which  in- 
volves the  removal  of  any  portion  of  the  individual. 
In  the  ordinary  course  of  gynecological  surgery  the 
ovaries  are  very  frequently  removed,  either  for  dis- 
ease or  for  the  threat  of  it.  This  operation  of  "  dou- 
ble oophorectomy,"  as  it  is  called,  is  simple  and  expe- 
ditious; and  though  it  was  at  one  time  performed 
far  too  freely,  it  is  a  justifiable  and  necessary  pro- 
cedure in  many  cases.  The  chief  objection  to  it, 
apart  from  the  permanent  sterility  which  necessarily 
follows  it,  is  that,  as  we  now  know,  the  ovaries  pro- 
duce not  only  the  germ-cells  from  which  future  gen- 
erations spring,  but  also  what  is  called  an  "  internal 
secretion,"    a    fluid   of   still   unknown    composition 


SURGERY  AS  IT  IS  217 

which  is  contributed  to  the  blood  as  it  passes  through 
the  ovaries,  and  has  most  important  influences  upon 
not  only  the  body,  but  also  the  temperament  and 
womanliness  of  the  woman.  The  more  we  learn  of 
the  so-called  u  ductless  glands,"  the  more  do  we 
respect  the  principle  of  internal  secretion;  and  the 
surgeon  to-day,  who  has  learnt  the  astonishing  conse- 
quences which  follow  removal  of  the  thyroid  gland, 
must  be  well-assured  before  he  consents  to  remove 
any  gland  that  contributes  an  internal  secretion  to 
the  blood. 

The  importance  of  the  racial  glands,  not  only  as 
containing  the  germ-plasm,  but  also  as  chemical 
laboratories,  performing  some  notable  though  ob- 
scure services  for  the  individual,  is  not  generally 
recognised  to  be  true  for  both  sexes,  and  the  first 
point  on  which  it  is  necessary  to  insist  is  that  the 
operation  proposed  for  the  sterilisation  of  certain 
individuals  who  come  under  the  ban  of  negative 
eugenics,  but  who  should  not  be  segregated,  is  in  no 
case  a  removal  of  the  racial  glands.  After  the  op- 
eration, as  before  it,  the  internal  secretion  of  these 
organs  is  contributed  by  them  to  the  blood  which 
circulates  through  them,  nor  is  there  any  reason  why 
it  should  be  otherwise,  seeing  that  neither  the  glands 
nor  the  blood  or  nerve  supply  to  them  are  even 
touched  by  the  surgeon  in  the  course  of  his  proce- 
dure. 

But  in  both  sexes  alike  there  are  minute  tubes, 
easily  accessible,  which  have  the  duty  of  conveying 
the  germ-cells  from  these  glands,  where  they  have 
been  formed  by  that  wonderful  process  of  gameto- 


218  SURGERY  AND  SOCIETY 

genesis  on  which  the  attention  of  so  many  biologists 
is  now  concentrated.  If  now  a  thread  be  tightly 
tied  round  any  of  these  tubes,  or,  better  still,  if  two 
such  threads  be  tied,  and  the  duct  divided,  or  even 
half  an  inch  of  it  removed,  between  them,  no  germ- 
cell  will  thereafter  be  able  to  traverse  it.  A  single 
thread  might  slip,  or  be  too  rapidly  absorbed,  or  not 
tightly  enough  tied;  but  the  use  of  two,  with  division 
of  the  duct  between  them,  involves  only  a  few  sec- 
onds' more  manipulation,  and  is  to  be  relied  upon 
thereafter.  If  this  be  done  upon  both  sides  of  the 
body,  so  far  as  the  future  is  concerned,  the  indi- 
vidual is  as  if  he  or  she  were  dead. 

So  far  as  the  present  is  concerned,  nothing  at  all 
has  happened.  The  intact  racial  glands  perform 
their  chemical  processes  as  before,  and  their  internal 
secretion  maintains  the  characteristics  of  the  indi- 
vidual. Nothing  more  has  happened  than  the  in- 
terposition of  a  mechanical  obstruction  to  that  trans- 
location of  the  germ-cells  which  is  necessary  for 
conception.  All  the  characteristics,  functions,  ap- 
petites, and  capacities  of  the  individual  are  re- 
tained in  tact:  but  those  which  are  concerned  with 
the  "  racial  instinct,"  as  I  prefer  to  call  it,  will  fail 
of  one  thing  only,  and  that  is  conception. 

The  service  of  Listerism  to  the  Eugenist  in  this 
connexion  is  clear.  It  offers  him  what  without  it  he 
could  not  have  —  a  measure  which  is  perfectly 
adapted  to  his  need,  and  which  can  be  recommended 
to  public  opinion  sincerely,  without  reserve,  and  in 
the  not  unjustifiable  hope  that  in  due  course  it  will 
be  accepted.     For  many  years  I  never  alluded  to 


SURGERY  AS  IT  IS  219 

this  subject  in  public,  either  by  voice  or  pen,  except 
before  medical  audiences.  It  is  a  most  notable  sign 
of  the  times  that  now,  after  only  a  brief  period  dur- 
ing which  we  have  uttered  the  word  in  public,  it  may 
be  and  is  freely  mentioned  wherever  eugenics  is 
studied,  has  been  discussed  by  the  present  writer  and 
others  in  many  responsible  gatherings  of  clergymen 
and  of  women,  and  has  had  attention  drawn  to  it  in 
the  Times  by  such  a  conservative  thinker  as  Profes- 
sor C.  S.  Loch.  We  owe  it  to  Listerism  that,  in 
commending  sterilisation  as  the  eugenic  demand  for 
certain  cases,  we  can  assure  the  public  that  these 
operations  of  vasectomy  or  salpingectomy,  which  do 
not  even  involve  opening  the  abdomen  in  either  case, 
are  perfectly  safe,  simple  and  certain;  and  that  no 
evil  consequences  of  any  kind  follow  from  them. 

At  one  time  I  feared  that  the  public  would  never 
tolerate  the  idea  of  surgical  sterilisation,  if  for  no 
other  reason  than  the  simple  one  that  it  seemed  im- 
possible to  get  anyone  to  understand  that  sterilisa- 
tion does  not  involve  any  form  or  degree  of  mutila- 
tion, or  of  injury  to  the  feelings  and  potencies  of  the 
individual.  It  was  therefore  with  much  hope  that 
one  turned  to  the  evidence  which  suggested  that  the 
Rontgen  rays,  accidentally  found  to  cause  sterility  in 
certain  cases,  might  be  intentionally  employed  for 
this  purpose.  At  the  time  of  writing,  however,  it  is 
by  no  means  clear  that  these  rays  are  safely  appli- 
cable for  the  purpose,  even  though  the  physicists,  as 
Sir  Joseph  Thomson  has  lately  pointed  out,  can  pro- 
vide us  with  the  means  whereby  the  "  soft "  or  non- 
penetrating, and  "  hard  "  or  penetrating  rays  can  be 


22Q  SURGERY  AND  SOCIETY 

separated.  Even  if  we  are  provided  with  an  appa- 
ratus which  produces  only  hard  rays,  so  that  injury 
to  the  skin  is  not  to  be  expected,  and  even  though 
the  evidence  from  the  lower  animals  suggests  that 
these  rays  may  cause  sterility  in  very  few  applica- 
tions, we  still  have  to  reckon  with  the  objections  that 
the  consequences  of  the  application  cannot  be  ob- 
served, that  the  impaired  fertility  might  be  restored, 
just  as  the  growth  of  hair  apparently  destroyed  by 
the  rays  is  often  restored,  and  that  the  rays  which 
affect  the  germinal  function  of  the  glands  may  also 
affect  the  processes  whereby  they  produce  their  in- 
valuable and  irreplaceable  internal  secretion.  None 
of  these  objections  have  any  counterpart  in  the  pro- 
cedure of  operative  sterilisation,  which,  indeed,  has 
to  contend  only  with  the  general  prejudice  against 
the  knife  and  misunderstanding  of  what  it  is  called 
upon  to  do  in  this  particular  case. 

Here,  as  in  every  other  instance  known  or  imagin- 
able, power  is  non-moral  in  itself,  and  may  be  used 
for  good  or  for  evil.  The  operation  of  vasectomy 
may  easily  be  turned  to  non-moral  or  to  grossly 
immoral  ends,  by  being  performed  for  the  con- 
venience of  the  individual.  That  is  a  question  which 
must  inevitably  be  faced  some  day,  quite  apart  from 
the  demands  of  eugenics.  Men  will  discover  that 
this  procedure  is  practicable  and  safe,  and  that  in 
less  than  ten  minutes  they  can  be  deprived,  forever, 
of  the  possibility  of  fatherhood  and  of  nothing  else; 
and  they  will  in  some  cases  approach  the  surgeon 
for  this  purpose.  The  demand  of  the  eugenist,  that 
this  operation  should  be  performed  in  certain  cases, 


SURGERY  AS  IT  IS  221 

remains  to  be  considered  on  its  merits,  and  cannot 
possibly  be  prejudiced,  in  the  minds  of  rational  per- 
sons, by  the  circumstance  that  the  operation  in  ques- 
tion —  which  was  not  invented  by  eugenists  —  may 
be  employed  for  illicit  ends.  And  I,  at  any  rate, 
am  one  of  those  who  believe  that  all  forms  of  knowl- 
edge and  power  are  to  be  accepted  since,  in  the  long 
run,  they  will  be  turned  to  the  service  of  wisdom  and 
her  children. 

In  the  domain  of  pelvic  surgery  which  we  owe  to 
Lord  Lister  must  be  included  practically  the  whole 
of  modern  gynecology.  Here,  also,  is  a  field  which, 
like  that  of  appendicitis,  is  fruitful,  and  has  been 
still  more  fruitful,  of  abuse.  The  abuses  will  dis- 
appear and  the  good  will  remain.  On  the  other 
hand,  the  occasions  for  resort  to  the  gynecological 
surgeon  will  gradually  diminish  in  accordance  as  we 
learn  how  to  prevent  the  disorders  for  which  his 
intervention  is  now  required.  As  we  have  already 
seen,  the  time  is  at  hand  when  Listerian  obstetrics 
will  be  available  for  all  mothers,  and  its  coming  will 
vastly  diminish  the  number  of  women  who  need 
operative  gynecology.  Further,  the  time  is  at  hand 
when  we  shall  begin  to  deal  with  those  eminently 
preventable  infections  from  which  our  shameful 
shame  and  still  more  shameful  carelessness  still  per- 
mit them  to  suffer;  and  when  we  have  controlled 
them  the  field  of  gynecological  surgery  will  be  very 
greatly  diminished. 

Nevertheless,  it  is  certain  that  for  some  time  to 
come  women  will  continue  to  suffer,  as  heretofore, 
from  tumours,  malignant  or  benign,   of  the  pelvic 


222  SURGERY  AND  SOCIETY 

organs,  for  which  nothing  but  surgical  intervention 
can  afford  them  any  relief.  It  is  such  a  common- 
place nowadays  to  accept  the  services  of  Listerism  in 
this  connexion,  and  so  impossible  to  come  across  a 
case  which  has  been  allowed  to  go  beyond  a  certain 
point,  that  old  pictures  of  patients  suffering  from 
untreated  ovarian  tumours  strike  one  as  simply  in- 
credible: how  could  people  have  existed  under  such 
conditions?  We  cannot  as  yet  explain  the  origin 
and  causation  of  either  simple  or  malignant  tumours; 
but  both  are  exceedingly  common  in  the  pelvic  or- 
gans of  women,  and  the  services  to  them  of  Listerian 
surgery  in  this  connexion  alone  can  scarcely  be  over- 
estimated; nor  are  they  for  one  moment  to  be  de- 
cried because  gynecologists  in  the  past  have  been 
willing  to  remove  the  ovaries  without  due  occasion. 
It  is  an  especial  purpose  of  this  chapter  to  demon- 
strate the  liberty  which  Listerism  affords  the  sur- 
geon to  deal  with  all  manner  of  conditions  which  do 
not  threaten  life,  or  even  health.  Surgery  is  now  so 
far  from  being  a  desperate  remedy  for  desperate 
diseases  that  it  may  freely  be  invoked  for  merely 
aesthetic  purposes,  as  we  shall  later  see.  It  may  ac- 
complish what  would  at  first  hearing  seem  to  be  utter 
impossibilities,  as  in  the  recently  recorded  case  of  a 
man  who  accidentally  chopped  off  a  finger,  which 
he  casually  deposited  in  his  pocket,  where  it  lay  in 
tobacco  dust  and  similar  rubbish,  whilst  he  walked 
four  miles  to  a  doctor  who,  after  cleansing  it,  was 
able  to  restore  it  in  such  a  fashion  that  it  has  done 
its  customary  duty  since.  In  the  whole  realm  of 
so-called   orthopaedic   surgery   we    find   possibilities 


SURGERY  AS  IT  IS  223 

which  are  almost  daily  being  further  exploited  by 
the  surgeons.  The  case  has  been  already  quoted  of 
the  deliberate  making  of  four  compound  fractures 
for  nothing  more  serious  than  knock-knees.  But 
this  is  only  one  instance  of  many.  Deformities,  in- 
juries and  paralyses  of  the  lower  limbs  are  very 
common,  and  since  they  will  tolerate  any  kind  of 
surgical  interference,  provided  it  be  Listerian,  they 
are  now  constantly  dealt  with  quite  apart  from  any 
compelling  necessity.  The  surgical  treatment  of 
flat-foot  is  not  very  satisfactory,  but  much  may  be 
done  for  various  forms  of  club-foot.  Some  of  the 
small  bones  of  the  deformed  feet  may  be  removed 
or  modified  in  shape  without  fear  of  subsequent  in- 
flammation, and  very  often  great  advantage  accrues 
to  the  victim  of  the  deformity. 

Recently  much  more  astonishing  things  have  been 
done  in  the  way  of  surgical  interference  with  bones 
and  muscles  and  nerves.  Bony  tissue  can  be  trans- 
planted successfully.  The  tendons  of  muscles 
which  are  incurably  paralysed  can  be  attached  to 
normal  muscles,  which  are  thus  enabled  to  exercise 
a  pull  upon  the  spot  which  the  paralysed  muscle  used 
to  control.  Similar  operations  can  be  performed 
with  nerves  for  the  palliation  of  paralysis,  and  it  is 
astonishing  to  observe  the  degree  of  manipulation 
to  which  they  will  submit.  Orthopaedics  is  now  one 
of  the  most  prosperous  and  useful  branches  of  sur- 
gery, and  since  we  are  as  yet  entirely  without  any 
key  to  the  control  of  congenital  deformities  such  as 
club-foot,  or  the  prevention  or  cure  of  the  infection 
which  produces  infantile  paralysis,  and  since  we  shall 


224  SURGERY  AND  SOCIETY 

always  have  accidents  with  us,  it  is  evident  that  this 
branch  of  surgery  has  an  assured  future,  and  will 
doubtless  be  doing  good  work  every  day  when  the 
surgery  of,  say,  cancer  or  syphilis  will  have  ceased 
to  exist. 

The  surgery  of  the  thorax  is  of  much  more  recent 
development  than  that  of  the  abdomen  or  pelvis, 
and  we  do  not  need  to  go  far  to  see  why  thoracic 
surgery  must  mostly  deal  with  matters  of  imperative 
necessity.  The  action  of  the  lungs  depends  entirely 
upon  the  existence  of  the  atmospheric  pressure  upon 
only  one  side  of  them.  We  breathe  by  enlarging 
the  capacity  of  the  thorax  so  that  air  is  bound  to 
rush  into  the  lungs  through  the  windpipe.  If  there 
be  a  hole  in  the  chest  the  air  will  rush  in  there,  and 
the  lung  will  immediately  collapse  and  remain  inex- 
pansible.  If  air  be  admitted  through  the  chest  wall 
to  the  outside  of  both  lungs  in  such  a  fashion,  neither 
of  them  will  expand,  and  the  patient  will  die  at 
once.  Here  is  evidently  a  fact  which  limits  the  ac- 
tivity of  the  surgeon,  for  even  if  he  confines  his 
efforts  to  one  lung,  he  can  scarcely  do  so  without 
throwing  it  out  of  action;  and  to  attempt  to  remove 
a  focus  of,  say,  tuberculosis  in  the  apex  of  a  lung, 
would  simply  be  to  deprive  the  patient  of  half  his 
vital  capacity  at  a  stroke.  This  is  not  to  say  that 
the  surgery  of  the  lung  has  not  made  great  advances 
in  recent  years,  but  there  are  evidently  somewhat 
sharp  limits  set  by  natural  necessity  to  its  powers. 

Between  the  lungs  there  lies  an  organ  still  more 
vital,  which  is  the  heart,  and  it  was  long  before  sur- 
geons dared  make  any  attempt  to  deal  with  this 


SURGERY  AS  IT  IS  225 

organ.  But  lately  so  much  progress  has  been  made 
that  only  the  description  of  a  recent  suggestion,  en- 
dorsed not  by  sensational  or  incompetent  men,  but 
seriously  considered  by  some  of  the  leaders  of  the 
profession,  will  suffice  to  indicate  its  measure. 

In  consequence,  usually,  of  the  inflammation  pro- 
duced in  the  course  of  rheumatic  fever,  the  valves 
especially  of  the  left  side  of  the  heart  may  become 
swollen,  or  rigid  or  adherent  in  various  ways,  which 
no  medicines  can  remove,  and  for  which  time  does 
nothing.  Sometimes  a  valve  becomes  incompetent, 
allowing  the  blood  to  regurgitate  through  it,  some- 
times constricted,  interfering  with  its  onward  pas- 
sage. These  are  typical  forms  of  true  heart  disease, 
and  they  will  continue  to  afflict  no  small  proportion  of 
mankind  until  we  can  completely  control  rheumatic 
fever  and  prevent  the  occurrence  of  the  valvular  in- 
flammation which  leaves  these  disastrous  sequels. 
Hitherto  the  resources  of  medicine  have  been  unable 
to  prevent  the  deformation  of  the  valves  which  is 
so  liable  to  occur  in  rheumatic  fever,  for  the  salic- 
ylates which  so  greatly  relieve  the  pain  do  little  or 
nothing  for  the  inflammation.  And  when  the  de- 
formation has  occurred,  medicine  can  do  nothing  ex- 
cept attempt  to  maintain,  as  far  as  possible,  the 
vigour  of  the  handicapped  heart.  But  it  has  lately 
been  suggested  that,  in  the  common  case  of  what  is 
called  mitral  stenosis,  where  a  comparatively  acces- 
sible valve  is  contracted  and  obstructs  the  passage 
of  the  blood  from  the  left  auricle  to  the  left  ventricle, 
the  surgeon  might  introduce  a  long  and  delicate 
knife-blade,  so  as  to  slit  up  the  obstruction.     This 


226  SURGERY  AND  SOCIETY] 

has  never  been  done,  and  I  am  far  from  certain  that 
it  ever  will  be  done.  We  are  much  more  likely  to 
obtain  control  of  rheumatic  fever  first,  and  so  dis- 
pose of  the  need  for  the'  surgeon  in  such  cases.  But 
the  fact  that  it  has  been  seriously  proposed  may  be 
offered  to  the  reader  as  some  criterion  of  the  possi- 
bilities which  are  open  to  modern  surgery. 

The  surgery  of  the  heart  already  has  much  to  its 
credit.  Whilst  valvular  disease  is  scarcely  accessible, 
and  degeneration  of  the  muscular  walls  of  the  organ 
demands  something  much  more  subtle  than  the  knife 
for  its  correction,  wounds  of  the  heart  offer  an  ob- 
vious field  for  the  surgeon  who  is  called  to  the  case  in 
time.  Especially  is  this  true  of  wounds  of  the  left 
ventricle,  which  constitutes  the  greater  part  of  the 
front  of  the  heart,  and  has  very  thick  walls.  Wounds 
inflicted  there  may  be  dealt  with,  and  foreign  bodies, 
such  as  the  broken-off  end  of  a  hatpin,  may  be  re- 
moved. But  there  is  at  least  one  case  on  record 
which  is  much  more  remarkable. 

Commonly,  as  we  should  expect,  wounds  which 
penetrate  the  wall  of  any  of  the  chambers  of  the 
heart  are  fatal.  The  blood  pours  through  them  into 
the  bag  wherein  the  heart  lies,  and  shortly  accumu- 
lates to  such  an  extent  that  the  organ  no  longer  finds 
room  in  which  to  work,  and  comes  to  a  standstill. 
Probably  there  is  only  one  case,  since  time  began,  in 
which  a  penetrating  wound  of  the  heart  has  not 
proved  fatal  in  this  fashion.  In  the  case  in  question, 
which  was  reported  some  years  ago  in  Berlin,  the 
left  ventricle  was  completely  pierced,  and  when  the 
surgeon,  hastily  summoned,  reached  and  exposed  the 


SURGERY  AS  IT  IS  227 

heart,  he  found  a  small  stream  of  blood  escaping 
from  the  ventricle  through  the  wound  at  every  beat. 
The  surgeon  made  good  the  damage  in  time,  sewed 
up  the  pierced  heart,  and  was  rewarded  by  the  com- 
plete recovery  of  the  patient. 

We  may  turn  now  to  the  surgery  of  the  head,  and 
particularly  to  intra-cranial  surgery.  We  shall  not 
understand  the  possibilities  here,  however,  unless  we 
consider  what  is  meant  when  we  speak  of  the  brain 
as  a  vital  organ. 

In  the  case  of  the  heart,  we  found  that  a  vital 
organ  may  be  wounded,  even  to  complete  perfora- 
tion, without  causing  death.  In  other  words,  only 
a  portion  of  this  organ  is  really  vital,  in  the  present 
sense  of  the  word.  If  certain  cells,  constituting  the 
so-called  "  intrinsic  ganglia  "  of  the  heart,  be  dam- 
aged by  a  knife  or  a  bullet,  the  heart  will  certainly 
cease  to  beat  once  and  for  all.  The  same  is  true  of 
the  brain.  In  the  very  lowest  and  oldest  portion  of 
the  brain,  to  which  no  surgeon  has  ever  penetrated, 
we  find  an  area  which  is  really  "  vital,"  like  the  in- 
trinsic ganglia  of  the  heart.  This  portion  of  the 
brain,  known  as  the  bulb  or  medulla  oblongata,  con- 
tains certain  nervous  centres  which  control  the  beating 
of  the  heart,  and  the  action  of  the  lungs  —  or,  rather, 
of  the  muscles  of  inspiration.  Damage  of  these 
areas  is  certainly  mortal,  and  we  may,  therefore,  call 
the  medulla  oblongata  a  vital  organ.  Indeed,  the 
older  physiologists,  who  discovered  the  "  respiratory- 
centre  "  in  the  bulb,  damage  of  which  causes  final 
arrest  of  the  breathing,  called  this  centre  the  punctum 
vitale,  or  vital  point  of  the  body. 


228  SURGERY  AND  SOCIETY 

Once  we  leave  the  bulb,  however  —  or,  rather,  a 
few  microscopic  points  in  the  centre  of  it  —  we  can 
no  longer  look  upon  the  brain  as  a  vital  organ. 
Accident  or  disease,  we  discover,  may  compress,  or 
starve  of  their  blood,  or  even  dissolve  completely 
away,  large  portions  of  it,  which  may  include  any 
portion  whatever  outside  the  bulb,  and  life  may  be 
maintained.  An  accident  in  a  mine  has  bodily  re- 
moved practically  the  whole  of  the  frontal  portion  of 
the  brain,  in  a  man  who  subsequently  resumed  his 
work,  apparently  without  particular  impairment  of 
his  —  doubtless  very  moderate  —  intellectual  pow- 
ers. Bullets  have  done  extraordinary  things  in  the 
brain  without  destroying  life.  So  have  the  spiro- 
chate  of  syphilis,  the  tubercle  bacilli,  the  cocci  of 
surgical  inflammation,  and  a  host  of  other  parasitic 
organisms.  In  certain  conditions  great  areas  of  the 
brain  are  absorbed  and  cavities  take  their  place.  In 
others,  the  blood  supply  to  various  areas,  sometimes 
of  great  size,  is  cut  off,  and  they  consequently  die 
and  are  replaced  by  fibrous  tissue,  chalky  masses  or 
other  substances  which  are  certainly  not  living  brain 
tissue :  and  the  patient  manages  to  survive. 

Plainly,  then,  no  portions  of  the  brain  are  necessary 
to  life  except  the  bulbar  centres  for  the  control  of 
the  circulation  and  the  respiration.  And  further, 
the  brain  has  remarkable  powers  of  resistance  to 
mechanical  shock,  and  is  by  no  means  liable  to  sur- 
render merely  because  it  is  touched  —  even  though 
the  touch  be  that  of  a  bullet  which  has  penetrated 
the  skull. 

Of  course  we  are  all  aware  that  certain  kinds  of 


SURGERY  AS  IT  IS  229 

mechanical  injury  may  very  seriously  arrest  the  nor- 
mal functions  of  the  brain  for  a  considerable  period, 
as  in  the  familiar  case  of  what  we  call  "  concussion 
of  the  brain."  What  exactly  happens  in  such  cases 
we  do  not  know,  but  the  injury  is  of  a  special  kind, 
which  could  not  be  reproduced,  for  instance,  by  the 
knife  even  if  a  surgeon  desired  to  do  so.  To  or- 
dinary irritation  the  brain  is  extraordinarily  indiffer- 
ent, and  this  most  paradoxical  fact  about  the  organ 
of  sensation  is  undoubtedly  of  the  utmost  value  in 
cranial  surgery.  The  seat  of  all  our  sensations  is 
the  brain.  If  someone  steps  on  our  corns,  certain 
cells  in  the  brain  are  disturbed  and  we  consequently 
feel  pain.  Every  minutest  area  of  the  skin  is  repre- 
sented in  the  brain,  as  is  proved  by  our  response  to 
stimulations  of  pressure,  heat,  and  cold.  The  or- 
dinary pressure-sense  of  touch  is  known  to  be  repre- 
sented in  certain  areas  on  the  external  aspect  of  the 
brain:  whenever  we  feel  a  touch  we  feel  it  there. 
But  if  this  very  area  of  the  brain,  in  which  all  touches 
are  felt,  be  itself  touched  it  feels  nothing.  It  is  a 
genuine  paradox,  and  a  most  significant  one. 
Amongst  its  numerous  and  important  consequences 
there  is  this  for  the  surgeon  —  that  the  brain  is  not  a 
particularly  sensitive  organ  to  handle.  Now  the 
skin  is :  and  one  of  the  dangers  of  a  superficial  burn, 
for  instance,  is  that  many  injurious  influences  pass 
from  the  damaged  cutaneous  nerve  to  the  brain,  pro- 
ducing some  kind  of  malnutrition  which  expresses 
itself  in  what  we  call  shock,  and  may  have  fatal 
consequences.  Thus  the  skin,  and  all  organs  what- 
soever which  are  richly  supplied  with  sensory  nerve- 


230  SURGERY  AND  SOCIETY 

endings,  must  be  cautiously  treated  by  the  surgeon, 
and  irritated  as  little  as  possible.  But  just  because 
the  brain  itself  is  not  supplied  with  sensory  nerve 
ends,  the  handling  of  it  does  not  send  impulses  to 
disturb  the  nerve  cells  which  lie  so  very  near  its  sur- 
face. The  exposed  brain  is  insensitive  to  touch  and 
pain  if  handled  without  anaesthesia,  and  it  thus  sub- 
mits to  a  moderate  amount  of  manipulation  in  surgi- 
cal procedure  without  any  of  the  consequences  which 
might  be  expected  to  follow  the  touching  of  the  cen- 
tre of  all  sensation. 

There  are  thus  none  of  the  antecedent  reasons 
which  might  have  been  anticipated  against  the  sur- 
gery of  the  brain,  nor  does  it  present  any  excep- 
tional problems.  The  cranium  has  to  be  passed 
through,  and  the  surgeon  must  necessarily  produce 
a  compound  fracture  of  the  skull.  As  we  have  seen, 
this  may  be  done  with  confidence  here,  as  in  other 
parts  of  the  body.  For  some  purposes  a  whole  flap, 
not  merely  of  the  scalp,  but  of  the  subjacent  cranium, 
may  be  turned  back,  so  as  to  allow  extensive  exposure 
of  the  brain  surface. 

It  is  not  to  be  denied,  of  course,  that  in  any  case 
this  is  a  serious  procedure,  and  it  is  commonly  con- 
fined to  the  meeting  of  indications  of  great  gravity, 
such  as  the  occurrence  of  raised  intra-cranial  pres- 
sure, leading  to  compression  of  the  brain  and  imme- 
diately threatening  life.  Intra-cranial  abscesses,  de- 
rived from  the  ear  or  elsewhere,  may  be  dealt  with, 
and  tumours  of  various  kinds  may  be  removed  with 
greater  or  less  success.  But  there  is  one  particular 
Operation,  of  quite  exceptional  interest,  which  is  per- 


SURGERY  AS  IT  IS  231 

formed  in  this  region  for  what  is  apparently  much 
slighter  cause,  and  which  illustrates  much  better  than 
any  other  the  powers  of  intra-cranial  surgery  as  it 
has  been  developed,  above  all  by  Sir  Victor  Horsley, 
in  recent  years. 

The  familiar  malady  called  neuralgia,  which  a 
French  physician  has  described  as  "  the  cry  of  the 
nerves  for  better  blood,"  occasionally  assumes  a  very 
severe  and  intractable  form.  Improvement  of  the 
general  health  and  treatment  with  iron  to  raise  the 
quality  of  the  blood,  prove  futile.  The  various 
anodyne  and  hypnotic  drugs  fail,  and  the  life  of  the 
patient  becomes  one  of  indescribable  anguish.  In 
such  cases  resort  may  be  had  to  surgery,  in  which 
there  is  evidently  some  hope,  since  painful  nerves 
can  at  least  be  divided,  if  nothing  else  is  of  any 
avail.  Sometimes  the  surgeon  may  simply  divide 
those  branches  of  the  fifth  cranial  nerve  which  go  to 
the  jaws,  and  it  may  be  that  this  measure  will  suffice. 
In  other  cases  —  probably  in  the  majority  of  this 
intractable  type  —  mere  division  of  the  branches  of 
the  nerve  is  of  no  more  use  than  division  of  the 
branches  of  the  ulnar  nerve  in  the  fingers  would  be 
of  use  in  preventing  the  symptoms  produced  by  hit- 
ting one's  "  funny  bone."  The  "  funny  bone  "  is 
really  the  ulnar  nerve  as  it  passes  behind  the  elbow, 
and  a  blow  delivered  there  causes  sensations,  more 
or  less  painful,  which  are  referred  to  the  fingers,  but 
have  not  their  origin  there,  nor  can  be  affected  by 
anything  done  there. 

Similarly,  in  the  cases  of  neuralgia  under  discus- 
sion, it  appears  that  the  seat  of  the  trouble  is  not,  as 


232  SURGERY  AND  SOCIETY 

it  usually  is,  in  the  branches  or  terminals  of  the  fifth 
nerve,  but  higher  up.  The  commonest  cause  of  neu- 
ralgia is  dental  decay,  and  such  neuralgia  is  to  be 
treated  by  dealing  with  the  teeth.  It  could  also  be 
effectively  controlled,  of  course,  by  dividing  the 
branch  of  the  fifth  nerve  which  conveys  impulses  to 
the  brain  from  the  peccant  part  of  the  jaw.  But 
in  the  cases  we  are  considering  it  appears  that  the 
seat  of  the  malady  is  in  a  collection  of  nerve  cells, 
lying  under  cover  of  the  brain,  which  is  called  the 
Gasserian  ganglion,  and  from  which  there  run  to 
the  jaws  and  elsewhere  those  branches  of  the  fifth 
nerve  to  which  the  pain  is  referred.  The  neuralgia 
is  really  a  symptom  of  what  is  presumably  a  species 
of  degeneration  of  the  Gasserian  ganglion;  and 
there  is  really  no  feasible  way  of  dealing  with  it  short 
of  the  heroic  project  of  removing  the  ganglion  alto- 
gether. 

This  excision  of  the  Gasserian  ganglion  is  the  bril- 
liant operation  by  which  Sir  Victor  Horsley  and 
others  have  been  able  to  restore  the  value  of  life 
to  so  many  elderly  persons  in  recent  years.  It  is  a 
truly  remarkable  feat.  The  first  case  in  which  I  saw 
it  performed  was  on  an  old  man  of  eighty-nine, 
whose  life  was  and  had  for  some  time  been  absolutely 
worthless  by  reason  of  his  neuralgia.  The  skull  was 
opened  and  a  large  area  of  the  brain  exposed;  the 
surgeons  worked  slowly  and  with  great  difficulty, 
step  by  step,  comparing  the  anatomical  features  they 
met  with  those  of  a  skull  held  in  a  parallel  position 
before  them.  At  last  the  superincumbent  portion 
of  brain  was  turned  aside  without  undue  laceration, 


SURGERY  AS  IT  IS  233 

and  the  Gasserian  ganglion  exposed  and  removed. 
The  patient  made  a  good  recovery,  and  though  he 
wandered  a  little  for  a  few  days,  he  contrived  to 
swallow  six  eggs  daily,  to  mention  nothing  else,  and 
soon  came  to  himself,  minus  his  neuralgia. 

It  need  hardly  be  pointed  out  that  there  is  a  pair 
of  fifth  nerves,  each  with  its  Gasserian  ganglion,  and 
that  only  one  can  be  reached  by  one  operation;  but 
there  are  many  cases  where  the  symptoms  are  one- 
sided, and  the  performance  of  Horsley's  operation 
effects  a  cure.  Nor  does  it  need  to  be  insisted  at 
this  stage  that  the  performance  of  such  an  operation 
except  under  the  most  perfect  aseptic  conditions 
would  be  quite  out  of  the  question.  In  the  first 
place,  if  microbes  were  introduced  they  would  set  up 
meningitis,  that  is  to  say,  inflammation  of  the  me- 
ninges or  lining  membranes  of  the  brain,  which  are 
very  much  encountered  and  dealt  with  in  this  opera- 
tion. In  the  second  place,  the  use  of  antiseptics 
such  as  carbolic  acid  or  mercuric  chloride,  which  are 
intensely  powerful  nerve  poisons,  is  evidently  quite 
out  of  the  question  in  dealing  with  the  tissue  of  the 
brain  itself.  Nothing  but  sterile  salt-solution,  closely 
similar  in  physical  and  chemical  properties  to  the 
natural  fluids  of  the  brain,  and  maintained  at  the 
temperature  of  the  blood,  will  satisfy  the  surgeon 
who  wishes  for  success  in  such  a  very  difficult  and 
responsible  undertaking  as  this  operation;  and  this 
means  that  the  precautions  taken  to  render  every- 
thing, including  the  scalp  of  the  patient,  aseptic,  must 
be  as  thorough  and  as  perfect  as  possible. 

If  we  take  everything  into  consideration,  it  must 


234  SURGERY  AND  SOCIETY 

probably  be  agreed  that  the  operation  which  has  just 
been  described  is  the  most  remarkable  and  admirable 
feat  on  the  whole  range  of  surgery  at  the  present 
time.  Much  more  formidable  proceedings  have  been 
successfully  undertaken  in  the  lower  animals,  where 
the  responsibility  for  failure  does  not  exist,  and  there 
is  no  reason  to  suppose  that  we  have  reached  the 
limits  of  surgical  possibility,  nor  that  some  of  these 
operations  may  not  some  day  be  justifiably  performed 
upon  the  human  subject;  but  at  the  present  time 
this  is  the  furthest  that  surgery  is  entitled  to  go, 
and  only  those  who  have  seen  the  operation  and 
realised  a  few  of  its  difficulties  can  appreciate  how 
far  that  is. 

The  surgery  of  the  ear  is  also  well  worthy  of  men- 
tion in  this  region  of  the  body.  I  do  not  mean  the 
external  ear,  though  it  is  true  that  cases  of  grafting 
this  organ  have  been  reported  which  are,  at  least, 
illustrations  of  the  meaning  of  the  aseptic  principle. 
The  external  ear,  however,  is  not  the  ear,  nor  any- 
thing like  it.  The  real  ear  is  contained  inside  the 
hardest  bone  in  the  body,  hence  called  the  petrous 
temporal  bone,  and  it  is  connected  with  the  nose  and 
throat  by  means  of  a  narrow  canal  called  the  Eu- 
stachian tube.  This  anatomical  fact  is  of  enormous 
pathological  significance,  for  it  invests  with  special 
risk  every  infectious  condition  of  the  nose  or  throat. 
Typically  in  such  a  common  malady  as  scarlet  fever, 
certain  organisms  of  ordinary  inflammation  are  apt 
to  join  forces  with  the  hitherto  unidentified  microbe 
that  produces  the  original  infection.  Very  often  the 
inflammation  in  the  throat  spreads  along  one  or  both 


SURGERY  AS  IT  IS  235 

Eustachian  tubes,  the  microbes  find  themselves  in 
that  air-chamber  inside  the  temporal  bone  which  is 
called  the  middle  ear,  and  there  is  set  up  middle-ear 
disease,  with  all  its  possible  consequences.  There  is 
terrible  pain;  the  drum  of  the  ear  is  perforated  and 
a  discharge  appears  externally,  the  child  being  deaf- 
ened for  life ;  the  roof  of  the  middle  ear,  only  a  thin 
plate  of  bone,  may  give  way,  and  meningitis  or  an 
abscess  of  the  temporal  lobe  of  the  brain,  which  lies 
over  the  middle  ear,  may  follow;  and  very  often  the 
infection  spreads  into  the  mastoid  portion  of  the 
bone,  which  is  the  familiar  rounded  projection  behind 
the  external  ear. 

None  of  this  should  have  happened,  and  I  pur- 
posely recount  some  of  the  pathological  details  in 
order  to  insist  that  measles  and  whooping-cough  and 
scarlet  fever,  and  even  severe  colds  in  the  head  in 
children,  must  be  treated  far  more  seriously  than  they 
are  now,  if  we  are  to  do  our  duty.  Whenever  the 
nose  and  throat  are  involved  in  inflammation  there 
is  risk  to  the  middle  ear,  in  consequence  of  the  ex- 
istence of  the  Eustachian  tube,  and  this  risk  is  one  to 
which  no  limits  can  be  assigned.  Further,  middle- 
ear  disease  does  irremediable  harm  to  the  hearing. 
The  surgeon  may  do  great  things,  but  he  cannot  re- 
pair a  perforated  ear-drum,  and  it  is  a  most  serious 
calamity  when  such  perforation  occurs.  If  we 
rightly  regarded  measles  and  other  complaints  which 
endanger  the  middle  ear,  we  should  treat  them  with 
assiduous  care  from  the  first,  paying  scrupulous  at- 
tention to  the  condition  of  the  mouth  and  nose.  We 
should  thus  undoubtedly  prevent  any  aural  compli- 


236  SURGERY  AND  SOCIETY 

cations  whatever  in  practically  all  cases,  and  the  ques- 
tion of  surgery  would  fortunately  not  arise.  There 
are  permanently  deafened  children  all  over  the  coun- 
try, and  plenty  more  being  made  every  day  for  lack 
of  knowledge  and  humanity  and  real  statesmanship 
in  this  respect,  and  it  is  not  surgery  that  will  provide 
a  remedy  for  such  cases  in  the  future. 

By  the  time  when  the  surgeon  can  be  of  any  use, 
the  hearing  has  already  been  impaired  forever, 
and  that  is  sufficient  reason  for  insisting  that  these 
cases  ought  never  to  go  so  far.  But  they  constantly 
do ;  and  then  the  surgeon  can  be  of  enormous  service. 
When  all  the  palliatives  have  failed,  he  is  called  in, 
and  performs  a  radical  operation  which  puts  an  end 
to  the  mischief  once  and  for  all,  thus  averting  the 
possible  consequences  to  the  brain  and  the  probable 
further  deterioration  of  the  hearing,  if  middle-ear 
discharge  is  allowed  to  go  on  indefinitely. 

And  here  it  may  be  well  to  refer  to  the  surgery  of 
adenoids.  No  doubt  this  is  as  far  removed  as  could 
well  be  from  the  surgery  of  the  Gasserian  ganglion 
or  the  radical  treatment  of  middle-ear  disease.  But 
the  existence  of  adenoids  directly  bears  upon  middle- 
ear  disease,  and  is  in  any  case  a  practical  matter  ex- 
celled in  importance  by  none  within  the  province  of 
minor  surgery. 

11  Adenoids  "  or  adenoid  growths  are  exceedingly 
common  in  the  throat  and  nose,  and  many  observers 
consider  that  they  are  far  commoner  than  they  used 
to  be.  A  very  large  proportion  of  modern  children, 
of  both  sexes  and  in  all  classes  of  society,  suffer  from 
them.     They  may  occasionally  disappear  of  their 


SURGERY  AS  IT  IS  237 

own  accord,  but  commonly  they  remain  throughout 
later  years  to  witness  the  permanent  damage  done  by 
them  during  the  period  of  development.  The  ob- 
jections to  them  are  very  numerous.  They  cause 
mouth-breathing  by  their  obstruction  of  the  nose, 
and  this  leads  to  various  risks  to  the  lungs,  since  air 
breathed  directly  through  the  mouth  is  not  filtered, 
moistened  or  warmed.  The  face  is  deformed,  the 
nose  becoming  swelled,  the  skin  puffy,  the  mouth 
permanently  open.  The  child's  blood  is  insufficiently 
aerated,  and  its  growth  and  its  intelligence  are  both 
interfered  with  in  consequence.  There  is  great  lia- 
bility to  colds,  which  may  infect  the  middle  ear. 
The  adenoid  tissue  is  probably,  even  between  the 
colds,  a  great  nest  for  microbes,  and  it  is  likely  that 
the  child  is  thus  being -chronically  poisoned  by  their 
products. 

The  modern  surgeon  has  a  very  short  way  with  all 
this.  A  brief  inhalation  of,  say,  ethyl  chloride,  caus- 
ing practically  instantaneous  unconsciousness,  lasting 
some  ninety  seconds  or  so,  will  suffice  for  the  surgeon 
to  remove  the  whole  mass  of  adenoids  in  one  piece, 
and,  if  necessary,  the  tonsils  as  well.  For  a  week 
or  ten  days  after  the  operation  the  child  should  be 
kept  indoors,  carefully  away  from  the  septic  dust  of 
the  streets,  whilst  the  denuded  surface  of  the  nose 
and  throat  heals.  Thereafter  all  the  symptoms  are 
put  an  end  to  once  and  for  all. 

The  value  of  this  procedure  may  here  be  insisted 
upon  for  my  own  convenience  as  well  as  for  its  place 
in  our  discussion.  The  removal  of  adenoids  is  an 
operation  which  is  constantly  being  recommended  to 


238  SURGERY  AND  SOCIETY 

parents,  many  of  whom  are  not  unnaturally  anxious 
about  it,  and  my  readers  frequently  ask  my  advice 
as  to  the  necessity  of  their  following  their  doctor's 
indications.  The  proper  reply  in  every  case  when 
such  a  question  is  asked  me  is  that  one  should  first 
choose  one's  doctor  and  then  trust  him  —  no  one  at 
a  distance  can  possibly  be  of  any  use ;  but  when  the 
subject  under  discussion  is  operation  for  adenoids  it 
is  always  my  duty  to  write  back  insisting  as  strongly 
as  possible  that  this  is  one  of  the  safest  and  most 
useful  little  procedures  in  the  whole  domain  of  sur- 
gery. 

Civilised  countries  in  general  are  full  of  children 
who  require  the  removal  of  adenoids.  In  Great 
Britain  at  the  present  time  we  have  got  so  far  as  to 
inspect  our  elementary  school  children,  and  medical 
inspection  has  demonstrated  that  we  are  attempting 
to  educate  hosts  of  helpless  children  who  have  cen- 
tral adenoids  and  suffer  from  colds  in  the  head  — 
which  they  hand  on,  after  development,  to  their 
neighbours  —  or  lateral  adenoids,  which  make  them 
deaf.  But  we  draw  the  line  at  this  point.  Not  to 
know  that  a  child  has  adenoids,  and  consequently  not 
to  treat  it  —  that  is  intelligible :  but  to  spend  money 
and  skill  on  ascertaining  their  existence,  and  then  to 
do  nothing  —  that  is  unintelligible,  but  it  is  our  pres- 
ent practice. 

Truth  to  tell,  directly  we  come  to  consider  modern 
minor  surgery,  with  its  possibilities,  we  discover  that 
we  have  a  great  duty,  hitherto  neglected,  towards 
the  nation's  children.  Their  eyes,  ears,  teeth,  noses 
and  throats  are  in  need  of  surgical  help,  not  in  thou- 


SURGERY  AS  IT  IS  239 

sands  but  in  millions  of  cases,  and  we  are  not  giving 
it  them.  This  ceases  to  be  defensible  on  any  ground, 
the  instant  that  the  power  is  put  into  our  hands, 
as  Lord  Lister  and  his  followers  have  done.  Our 
duty  is  measured  by  our  powers,  and  our  powers  are 
far  greater  than  any  but  the  few  realise.  For  our 
failure  to  use  them,  not  only  the  children  themselves, 
but  we,  and  our  more  fortunate  children  in  their 
turn,  pay  and  will  pay  a  heavy  price.  These  chil- 
dren whom  we  now  neglect  the  recruiting  sergeant 
will  shortly  reject,  and  later  we  may  study  them  at 
our  leisure  in  prison  and  workhouse  and  processions 
of  the  unemployed.  If  we  want  soldiers,  sailors, 
citizens,  fathers  and  mothers  for  the  future,  we  must 
attend  to  these  children  now.  The  policy  of  those 
who  promise  us  everything  we  may  desire  by  means 
of  military  training  is  to  be  rejected  summarily  and 
contemptuously  when  we  remember  first,  that  it 
leaves  out  the  more  important  sex  altogether,  and 
second,  that  it  has  yet  to  prove  its  capacity  to  grow 
new  teeth  or  ear-drums  or  eyes. 

The  powers  which  are  now  in  the  possession  of  the 
modern  surgeon,  which  are  not  confined  to  a  few 
men  of  exceptional  talent  and  opportunity,  but  are  the 
common  property  of  all  properly  trained  practition- 
ers, make  it  a  national  duty  to  provide  for  their  ap- 
plication to  the  nation's  children,  and  this  can  be 
effectively  done  in  one  way  and  in  one  only.  The 
out-patient  departments  of  the  hospitals,  in  any  case 
atrocious  anachronisms  which  ought  not  to  exist  in 
the  age  of  Pasteur,  cannot  possibly  cope  with  the 
need.     The  experiment  has  been  tried  by  ignorant 


240  SURGERY  AND  SOCIETY 

or  selfish  authorities  and  has  egregiously  failed,  as 
every  competent  person  knew  it  must.  In  connex- 
ion with  every  elementary  school  in  the  land  there 
must  be  a  school  clinic,  such  as  they  have  in  Ger- 
many, and  already  in  a  few  places  in  Great  Britain. 
Here  the  surgeon  will  find  his  most  beneficent  field 
of  action,  and  the  consequent  health  and  efficiency 
of  the  population  will  repay  the  cost  many  times 
over.  The  total  number  of  elementary  school  chil- 
dren at  this  moment  in  need  of  simple  Listerian  sur- 
gery is  enormous,  and  the  failure  to  deal  with  it 
simply  means  an  enormous  burden  later  on. 

One  particular  case  of  the  application  of  Listerism 
is  worthy  of  our  special  consideration  for  its  national 
importance.  I  refer  to  Listerian  dentistry.  We 
remember  that  the  surgeon's  duties,  confined  to 
blood-letting  or  little  more,  were  once  combined  with 
those  of  the  barber.  Nowadays  the  surgeon  has 
established  a  claim  to  our  respect  and  obtains  it. 
We  should  now  realise  that  the  dentist  of  former 
days  has  evolved  and  that  there  exists  in  his  place 
the  dental  surgeon,  a  practitioner  of  high  importance 
to  the  individual  and  the  State. 

When  surgery  meant  blood-letting  little  honour 
could  attach  to  it:  when  dentistry  meant  the  extrac- 
tion of  teeth,  by  means  of  the  blacksmith's  brawny 
arm,  it  could  claim  little  respect.  But  the  case  is 
very  different  now,  though  the  unfettered  practice 
of  unqualified  dentistry  is  a  very  grave  handicap 
upon  the  progress  of  the  profession,  and  obscures 
the  significance  of  the  change  which  has  been  brought 
about  in  recent  years.     The  modern  dentist,  of  the 


SURGERY  AS  IT  IS  241 

kind  whom  we  need  in  our  school  clinics,  is  a  surgeon, 
Listerian  in  training  and  practice,  who  specialises  in 
the  surgery  of  the  teeth  and  gums.  The  extraction 
of  a  tooth  is  to  him  a  last  resort,  a  confession  of 
despair,  just  as  the  amputation  of  a  limb  is  to  the 
general  surgeon.  His  object,  like  that  of  all  good 
surgery,  is  conservation,  and  his  enemy  is  the  microbe, 
the  enemy  of  surgeons  in  general. 

No  doubt  there  should  be  no  such  thing  as  dental 
decay.  But  unfortunately  we  have  to  accept  the 
facts  as  in  large  measure  uncontrollable.  The  hy- 
giene of  the  teeth,  which  is  essentially  Listerian,  will 
do  much  for  them,  and  so  will  a  wisely-chosen  diet, 
which  gives  them  enough  work  to  do.  There  should 
certainly  be  no  such  thing  as  dental  decay  due  to  our 
permitting  a  child  to  go  to  sleep  with  chocolate  or 
soft  biscuit  enveloping  the  necks  of  its  teeth.  The 
consequences  of  our  present  neglect  of  dental  hygiene 
are  not  to  be  gainsaid,  and  no  kind  of  surgery  is  the 
real  remedy  for  them:  but  there  will  apparently  al- 
ways remain,  in  civilised  communities,  a  very  large 
number  of  persons  whose  teeth  decay  in  spite  of  all 
precautions.  We  cannot  entirely  revert  to  a  primi- 
tive diet,  such  as  is  diet  and  dentifrice  in  one;  and 
even  if  we  could,  it  may  be  that  many  of  us  are 
destined  to  have  bad  teeth  in  any  case,  having  in- 
herited the  tendency  from  our  parents.  There  is 
something  to  be  said  for  the  view  that,  in  part  at 
least,  the  present  prevalence  of  dental  decay  is  due 
to  the  fact  that  persons  with  naturally  non-resistant 
teeth  have  not  been  eliminated  by  natural  selection 
in  recent  generations  as  they  would  have  been  in 


242  SURGERY  AND  SOCIETY 

the  absence  of  modern  cooking  and  modern  den- 
tistry. It  is  probable,  therefore,  that  the  problem 
of  dental  caries  will  remain  with  us,  and  it  is  much 
more  likely  to  become  accentuated  in  the  future  than 
to  disappear. 

Here  dentistry  of  various  kinds  steps  in.  The 
oldest  and  rudest  is  that  which  simply  removes  any 
tooth  which  persistently  gives  pain,  and  of  this  no 
more  need  be  said  than  that  the  modern  dentist,  in 
the  relatively  few  cases  when  he  is  compelled  to 
perform  an  extraction,  should  certainly  be  Listerian 
in  his  after-treatment,  and  keep  the  mouth  clean  with 
antiseptic  washes,  so  as  to  prevent  the  patient  from 
11  catching  cold,"  as  he  calls  it,  in  the  wounded  gum. 

The  more  advanced  forms  of  dentistry  are  con- 
servative, as  distinguished  from  the  dentistry  of  ex- 
traction, which  is,  or  ought  to  be,  literally  radical. 
One  form  of  conservative  dentistry  may  be  styled 
mechanical.  It  is  the  so-called  American  dentistry, 
and  a  very  clever  thing  it  is.  A  dentist  of  this  school 
does  not  regard  a  tooth  as  in  any  sense  a  living  thing, 
but  as  a  hard  inanimate  object  which  is  to  be  dealt 
with  on  mechanical  lines.  He  does  not  look  at  den- 
tal decay  as  in  any  way  a  problem  in  pathology  com- 
parable to  the  other  morbid  consequences  of  bacterial 
activity,  but  rather  as  a  mechanical  injury  due  to 
attrition,  hard  particles  in  the  food  or  what  not; 
and  of  course  it  follows  that  he  does  not  contemplate 
the  possibility,  which  would  naturally  present  itself 
to  a  surgeon,  that  any  of  his  manipulations  may  in- 
volve lowering  the  vital  resistance  of  the  tooth. 
Thus  in  order  to  get  access  for  his  unquestionably 


SURGERY  AS  IT  IS  243 

skilful  and  elegant  technique,  he  is  quite  willing  to 
wedge  teeth  apart  to  any  extent,  being  totally  un- 
aware that  he  is  thereby  damaging  the  vital  connex- 
ions of  the  root,  injuring  delicate  blood-  and  lymph- 
vessels,  and  nerve  fibrils,  so  that  in  time  the  root 
will  atrophy,  and  be  unable  to  support  an  artificial 
crown  should  one  be  desirable  at  a  later  date.  It 
is  not  asserted  that  the  best  American  dentists  do 
this  sort  of  thing  nowadays,  nor  that  their  methods 
differ  essentially  from  those  of  the  best  dental  sur- 
geons elsewhere;  but  the  so-called  "American  den- 
tistry "  which  is  advertised  in  Great  Britain  is,  gen- 
erally speaking,  a  thing  to  shun,  chiefly  on  the 
ground,  already  indicated,  that  the  operator  looks 
upon  his  task  as  a  purely  mechanical  one,  whereas  it 
is  really  a  problem  in  applied  physiology.  It  has 
only  to  be  added  that  the  high  development  of  me- 
chanical dentistry  in  America,  and  the  inventiveness 
of  American  dentists  in  the  matter  of  instruments, 
have  been  and  are  of  the  greatest  value  to  the  best 
scientific  dentistry  of  the  present  day. 

Modern  Listerian  surgery  is  as  conservative  in  deal- 
ing with  the  teeth  as  in  any  other  part  of  the  body, 
and  proceeds  upon  the  same  assumptions.  Its  prob- 
lem is  to  protect  the  tooth  against  microbes,  which 
in  any  case  abound  in  the  mouth  of  the  most  scrupu- 
lously clean,  and  certain  varieties  of  which,  if  pres- 
ent and  active,  are  capable  of  forming  acids,  usually 
lactic  acid,  from  such  substances  as  sugar  —  whether 
taken  as  such  or  formed  in  the  mouth  by  the  fermen- 
tation of  starch  —  with  the  consequence  that  the 
enamel  of  the  teeth  is  slowly  dissolved.     The  busi- 


244  SURGERY  AND  SOCIETY 

ness  of  the  surgeon  in  these  circumstances  is  as  far 
as  possible  to  apply  his  ordinary  principles  of  surgical 
cleanliness  to  the  mouth ;  and  to  operate  on  Listerian 
lines  when  his  antiseptic  precautions  have  failed,  as 
they  frequently  will.  Let  us  note  how  these  two 
considerations  work  out  in  practice. 

We  have  already  seen  that  the  process  of  sterilisa- 
tion does  not  merely  comprise,  if  it  is  to  be  success- 
ful, the  free  use  of  an  antiseptic  solution.  The  sur- 
geon must  use  a  nail-brush  besides  dipping  his  fingers 
in  carbolic  lotion.  So  also  in  the  case  of  the  teeth. 
The  mechanical  removal  of  microbes  is  the  point  of 
first  importance.  The  diet  of  the  lower  animals  and 
of  savages,  who  use  no  antiseptic  mouth  washes,  per- 
forms the  cleansing  process  with  admirable  results, 
and  we  must  imitate  them,  partly  by  the  inclusion  in 
the  diet  of  such  things  as  wholemeal  bread  and 
raw  apples,  partly  by  the  judicious  use  of  the  tooth- 
brush after  meals  and,  above  all,  before  going  to 
bed.  Our  dentifrice  will  be  nicely  adapted  to  the 
needs  of  the  case  by  being,  first  of  all,  solid,  in  the 
form  of  a  powder,  so  as  to  aid  the  mechanical  action 
of  the  brush;  secondly,  antiseptic,  so  as  to  kill  mi- 
crobes ;  and  thirdly,  antitoxic,  so  as  to  neutralise  their 
toxins.  In  this  case  the  toxins  are  simple  acids,  and 
therefore  our  antitoxin  is  merely  chalk  or  bicarbonate 
of  soda  —  which,  being  alkaline,  are  sufficient  for 
the   purpose. 

In  his  operations  the  dental  surgeon  lays  it  down 
as  a  first  principle  that  he  must  safeguard  the  vital 
resistance  of  the  teeth.  He  knows  that  the  crown 
of  a  tooth  is  chiefly  nourished  through  the  vessels 


SURGERY  AS  IT  IS  245 

of  the  pulp,  and  the  root  through  the  vessels  which 
pass  into  it  from  its  surroundings.  He  knows  also 
that  any  injury  to  the  nerve  or  blood  supply  alters 
the  vital  condition  and  even  the  chemical  composi- 
tion of  the  tooth,  so  that  its  resistance  will  be  im- 
paired; and  therefore  he  will  not  wedge  teeth  apart 
in  such  a  fashion  as  to  condemn  their  roots  to  die  of 
starvation,  and  be  worthless  for  crowning  purposes 
at  a  later  date. 

On  the  more  positive  side  the  services  of  Listerism 
in  modern  dental  surgery  are  of  the  highest  order. 
The  skilled  operator  need  scarcely  ever  remove  a 
tooth;  and  in  many  cases  he  may  prefer  the  anti- 
septic medication  and  sealing  up  even  of  an  appar- 
ently worthless  root,  to  its  extraction,  for  he  knows 
that  the  removal  even  of  a  root  favours  atrophy  of 
the  jaw  and  consequent  ageing  of  the  face.  Even 
severe  inflammation  of  the  pulp,  leading  to  death 
of  the  contained  nerve,  need  not  entail  the  loss  of 
the  tooth,  for  the  surgeon  may  penetrate  to  the 
canal,  remove  the  worthless  and  usually  highly  bac- 
terial contents  and,  by  careful  antiseptic  dressing  of 
the  canal  he  may  save  the  tooth  or,  at  the  least,  the 
root.  My  own  experience  in  dentistry  has  been  en- 
tirely that  of  a  patient,  and  I  cannot  discuss  all  the 
various  applications  of  Listerism  in  this  field,  which 
are  familiar  to  the  modern  dental  surgeon,  but 
enough  will  have  been  said  to  show  that  Listerism 
is  of  high  and  increasing  value  here,  and  that  its 
very  existence  is  a  sufficient  reason  for  demanding 
that  the  status  of  the  dentist  should  be  raised,  that 
unqualified  practice  should  be  controlled  by  law  much 


246  SURGERY  AND  SOCIETY 

more  stringently  than  at  present,  that  every  dentist 
should  be  a  fully  qualified  surgeon,  specialising  in 
dental  surgery,  and  that  such  a  surgeon  should  be  in 
charge  of  a  dental  clinic  in  association  with  every 
school  where  the  nation's  citizens,  of  whatever  class, 
are  being  reared. 

Briefly,  the  facts  in  London  at  the  present  time 
are  that  there  are  not  enough  dentists  to  be  had  even 
for  the  purpose  of  extracting  the  unsavable  teeth  of 
the  three-quarters  of  a  million  of  children  in  our 
elementary  schools;  and  of  course  there  does  not 
begin  to  be  any  provision  of  dentists  in  sufficient 
numbers  to  practise  what  is  really  required.  The 
few  dentists,  even  in  this  wealthiest  of  cities,  who 
possess  really  adequate  surgical  qualifications,  are  as 
a  rule  much  overworked  by  the  demands  of  the  upper 
and  middle  classes,  and  the  dentists  able  to  save 
the  teeth  of  the  children  of  the  lower  classes  simply 
do  not  exist.  A  few  years  later  these  children  will 
apply  in  large  numbers  for  admission  to  the  army 
and  will  be  rejected  by  the  medical  officer  on  the 
ground  of  their  defective  teeth,  which  conservative 
Listerian  surgery  could  easily  have  saved  a  few  years 
before.  If  only  the  champions  of  compulsory  mili- 
tary training  could  themselves  receive  some  training 
in  the  alphabetical  facts  of  our  national  existence ! 

Listerism  has  called  into  existence  in  our  day  a 
new  branch  of  surgery  which  may  be  called  plastic, 
cosmetic  or  constructive,  and  of  which  many  striking 
illustrations  might  be  cited. 

A  representative  case  of  this  type  of  surgery  is  to 
be  found  in  skin-grafting,  which  is  now  practised 


SURGERY  AS  IT  IS  247 

every  day,  and  confers  vastly  more  benefit  upon 
humanity  than  the  name  at  all  adequately  suggests. 
We  should  require  a  little  time  for  sober  consider- 
ation of  the  advantage  of  possessing  a  skin,  before 
we  could  rightly  estimate  the  boon  which  skin- 
grafting  daily  confers  upon  the  many  persons, 
young  and  old,  who  without  it  would  be  condemned 
to  grave  permanent  discomfort  and  danger.  Here 
is  an  instance  of  a  kind  of  surgery  which  will  always 
be  wanted,  for  there  is  no  reason  to  suppose  that 
mankind  will  ever  be  entirely  immune  from  acci- 
dents, even  if  the  opportunity  for  bad  burns  become 
less  frequent,  as  they  doubtless  will.  It  is  probably 
in  cases  of  burning  that  skin-grafting  is  most  often 
demanded.  Many  accidents  involve  considerable 
destruction  of  the  skin,  and  occasionally  the  surgeon, 
at  the  conclusion  of  an  operation,  may  find  that  there 
is  not  enough  available  skin  for  the  edges  to  meet. 
But  burns  are  of  everyday  occurrence,  and  it  is,  of 
course,  the  skin  pre-eminently  that  they  tend  to  de- 
stroy. A  burn  may  be  severe,  intensely  painful,  and 
dangerous,  without  involving  destruction  of  the  skin; 
but  many  burns  extend  somewhat  deeper  and, 
whilst  probably  much  less  painful,  the  nerve-ends 
being  destroyed,  completely  kill  the  entire  thickness 
of  the  skin.  In  such  a  case  the  general  laws  of 
repair  have  to  be  reckoned  with.  Skin  is  a  special- 
ised structure,  and  can  by  no  means  be  formed  ex- 
cept from  existing  skin,  or  from  those  elements  of 
the  germ  cells  which  are  destined  to  give  rise  to 
skin.  If,  then,  the  whole  thickness  of  the  skin  be 
destroyed,   the   subcutaneous  tissues,   thus   exposed, 


248  SURGERY  AND  SOCIETY 

are  entirely  impotent  to  form  any  substitute,  how- 
ever imperfect.  The  result  is  an  ulcer,  and  if  this 
is  to  become  what  the  surgeon  calls  a  healing  ulcer 
it  must  be  covered  over  by  the  growth  of  the  skin 
at  its  margins.  An  attempt  in  this  direction  will  be 
made  in  every  case  where  the  principles  of  Listerism 
are  applied  and  where  the  patient's  powers  are  not 
destroyed  by  diabetes  or  alcoholism  or  some  other 
form  of  poisoning.  But  when  the  area  of  destruc- 
tion is  a  large  one,  as  very  often  happens  in  cases  of 
burning,  the  marginal  skin  is  not  equal  to  the  tre- 
mendous task  of  covering  over  the  whole  area.  In 
such  cases  skin-grafting  is  the  only  hope  for  the 
patient,  and  this  procedure  can  now  be  successfully 
carried  out  upon  the  most  surprising  scale.  Thus 
in  a  recently  reported  case  practically  the  whole  of 
the  back  of  the  burnt  patient  was  successfully  cov- 
ered by  means  of  skin-grafting,  after  a  series  of 
operations  which  covered  a  period  of  fourteen 
months.  The  skin  to  be  grafted  must,  of  course, 
be  obtained  from  somewhere,  and  the  patient,  if 
otherwise  healthy,  or  friends  may  be  called  upon  for 
contributions.  These  are  taken  in  pieces  of  such  a 
size  that  the  skin  of  the  bereft  individual  may  be 
counted  upon  to  make  good  the  deficiency,  and 
though  the  new  skin  thus  formed  will  not  possess 
hairs  or  sweat-glands  that  is  of  small  importance. 

The  failure  or  success  of  this  operation  depends, 
above  all,  upon  the  application  of  Listerism.  The 
portions  of  grafted  skin,  set  down  upon  the  surface 
of  the  ulcer,  will  "  take  root,"  so  to  say,  and  grow 
outwards  until  they  join  hands  with  each  other  and 


SURGERY  AS  IT  IS  249 

with  the  native  skin  of  the  patient,  only  if  their 
vitality  is  not  impaired.  On  this  account  the  sur- 
geon must  scrupulously  keep  microbes  out  of  the 
case  altogether:  otherwise  his  grafts  will  die  where 
they  are  placed,  and  be  worse  than  useless.  But, 
further,  if  microbes  would  produce  poisons  fatal  to 
the  survival  and  growth  of  the  grafts,  it  must  not 
be  forgotten  that  such  antiseptics  as  carbolic  acid  or 
corrosive  sublimate  will  be  liable  to  produce  just 
the  same  result.  Clearly,  then,  skin-grafting  is  an 
operation  which  demands  the  most  perfect  develop- 
ments of  aseptic  surgery,  and  it  is  since  the  practice 
of  aseptic  surgery  was  devised  and  made  efficient 
that  skin-grafting  has  become  so  generally  successful 
and  so  widely  beneficent.  There  are  many  different 
ways  of  performing  the  operation,  and  surgeons  may 
discuss  the  best  source  of  the  skin,  the  thickness  to 
be  removed,  the  size  and  distribution  of  the  grafts, 
and  so  forth :  but  the  vital  point  is  that  the  vis  medi- 
catrix  Natura  shall  be  utilised  in  every  case,  and  for 
this  purpose  it  is  the  aseptic  method  that  matters. 
If  that  be  successfully  practised,  the  rest  will  follow. 
No  sooner  had  surgeons  realised  the  possibility 
of  grafting  skin  than,  as  might  be  expected,  they 
began  to  inquire  into  the  possibility  of  grafting  other 
tissues:  and  the  observation  of  one  successful  case 
of  skin-grafting  suffices  to  remind  the  thoughtful 
that  there  is  a  foolish  scepticism  as  well  as  a  wise, 
though  it  very  seldom  receives  the  castigation  it  de- 
serves. This  whole  question  of  grafting  is  not 
merely  important  from  the  point  of  view  of  prac- 
tical surgery,  but  also  interesting  from  the  point  of 


250  SURGERY  AND  SOCIETY 

view  of  experimental  physiology,  for  it  enables  us 
to  extend  indefinitely  our  comprehension  of  physio- 
logical processes  and  possibilities.  Enough  stress 
has  not,  indeed,  been  laid  on  the  enormous  services 
of  Listerism  as  an  instrument  of  the  physiologist, 
enabling  him  to  learn,  by  observation  in  the  case  of 
mankind,  and  experiment  in  the  case  of  the  lower 
animals,  many  facts  otherwise  inaccessible. 

Generally  speaking,  it  is  as  we  should  expect,  that 
tissues,  organs,  structures,  to  be  successfully  grafted 
must  be  derived  from  an  individual  of  the  same 
species  as  the  person  of  whom  they  are  now  hoped  to 
form  part.  This,  however,  is  by  no  means  an  in- 
variable rule,  and  many  portions  of  structure  derived 
from  the  lower  animals  may  be  caused  to  live  in 
animals  of  other  species  or  in  man. 

This  grafting  may  be  extended  to  entire  organs 
or  considerable  portions  of  organs,  and  practised 
with  success  provided  that  perfect  asepsis  be  pro- 
vided, for  the  two  sufficient  reasons  which  we  have 
already  discussed  in  the  case  of  the  skin.  Thus  it 
is  possible  to  graft  the  thyroid  gland,  carefully  re- 
moved from  a  living  animal,  in  the  body  of  another 
animal,  already  deprived  of  its  thyroid,  and  thus 
prevent  the  symptoms  which  follow  when  an  animal 
attempts  to  live  without  the  presence  of  the  secre- 
tion of  that  gland  in  its  blood.  In  the  human  dis- 
eases called  cretinism  and  myxoedema  the  patients 
suffer  from  thyroid  deprivation,  and  it  might  be 
quite  possible  to  cure  them  by  the  transplantation 
of  thyroid  tissue  from  another  individual,  if  it  were 
not  that  the   daily  administration  of  thyroid  sub- 


SURGERY  AS  IT  IS  251 

stance,  as  part  of  the  diet,  will  effect  all  that  is  nec- 
essary, without  risk  or  disadvantage.  The  trans- 
plantation of  many  other  organs  is  now  being 
studied,  and  the  consideration  of  the  possibilities 
leads  to  some  bizarre  conclusions  when  we  consider 
the  possible  transplantation  of  the  organs  in  which 
the  germ-cells  of  the  individual  are  contained. 

To  turn  to  the  more  practical  applications  of  these 
methods,  we  may  note  that  much  can  be  done  in 
the  way  of  tendon  grafting  or  transplantation.  A 
tendon  is  a  structure  chiefly  mechanical  in  composi- 
tion, and  entirely  mechanical  in  function,  being  sim- 
ply the  rope  through  which  a  muscle  exerts  its  pull, 
and  we  need  not  be  surprised  at  the  possibilities  in 
this  direction.  The  transplantation  of  bone  might 
be  thought  to  be  of  the  same  order,  but  bony  tissue 
is  very  much  more  vital  than  we  suppose,  and  suc- 
cess is  not  so  easily  obtained  in  this  case.  The 
transplantation  or  grafting  of  nerves  is  also  of  inter- 
est. If  we  think  of  a  nerve  as  merely  a  wire,  we 
might  expect  to  make  good  a  breach  of  continuity  in 
a  nerve  by  splicing  it,  or  joining  the  ends,  with  a 
piece  of  nerve  from  any  source.  A  nerve,  however, 
is  a  living  projection  from,  and  integral  portion  of, 
a  nerve  cell:  or  rather,  what  we  call  a  nerve  is  a 
bundle  of  many  such  projections.  If  a  nerve  be 
thought  of  from  this  point  of  view,  the  project  of 
nerve-grafting  takes  on  a  new  aspect:  nor  can  we 
expect  to  obtain  simple  and  immediate  results,  how- 
ever clean  and  deft  our  procedure.  But  the  oper- 
ation may  well  be  worth  performing  nevertheless, 
for  it  means  providing  a  bridge  or  scaffolding,  along 


252  SURGERY  AND  SOCIETY 

which  the  severed  nerve  fibres  which  are  still  in  vital 
continuity  with  the  cells  from  which  they  spring, 
may  grow,  and  strike  their  old  sheaths  —  now  filled 
with  mere  droplets  of  fat,  for  nerves  cut  off  from 
their  parent  cells  degenerate  and  die  —  and  fill  those 
sheathes  again  and  reach  down  to  their  old  ap- 
pointed terminals:  all  of  which  is  sufficiently  won- 
derful to  consider,  and  for  the  paralysed  patient 
who  finds  that  he  can  move  his  fingers  or  what  not 
again,  very  pleasant  to  experience. 

In  other  directions  reconstructive  surgery  may 
reach  a  very  high  pitch  of  achievement.  In  a  re- 
cently reported  American  case,  the  face  of  a  patient 
was  practically  destroyed  by  machinery,  and  the  sur- 
geons set  themselves  to  the  task  of  reconstructing 
it.  If  we  are  to  understand  their  success,  or  even 
their  making  the  venture,  we  must  remember  that 
the  facial  destruction  was  due  to  an  accident,  and 
that  they  had  healthy  tissues  on  which  to  work. 
There  is  at  least  one  form  of  disease,  still  common, 
to  say  nothing  of  leprosy,  where  the  face  may  be 
destroyed,  but  here  it  is  rotted  away  by  a  process 
of  poisoning  which,  even  if  arrested,  would  not 
leave  sufficient  of  the  vis  medicatrix  Natura  for  even 
the  aseptic  surgeon  to  count  upon  with  any  confi- 
dence. But  in  the  case  under  discussion  there  had 
been  no  such  devitalisation,  and  it  is  recorded  that 
the  surgeons  succeeded  in  transplanting  enough 
muscular  tissues  and  skin  for  the  making  of  a  new 
mouth,  with  which  the  patient  could  speak  again; 
and  finally,  by  the  adaptation  of  one  of  his  little  fin- 


SURGERY  AS  IT  IS  253 

gers,  they  are  said  to  have  succeeded  in  providing 
him  with  a  fairly  presentable  nose. 

The  modification  of  the  nose,  in  any  direction,  is 
certainly  well  within  the  possibilities  of  modern  sur- 
gery. There  is,  for  instance,  the  hideous  disfigure- 
ment of  the  so-called  "  gin-blossom  "  nose,  which  is 
not  uncommon  by  any  means  even  in  persons  who 
are  temperate  in  the  matter  of  alcohol.  This  can 
be  readily  shaved  down  to  a  suitable  pattern,  and 
will  proceed  to  heal  quite  satisfactorily  as  a  rule, 
without  skin-grafting,  for  enough  skin  cells  remain, 
after  the  overgrowth  has  been  removed,  to  renovate 
the  more  modest  surface  which  the  razor  leaves. 
If  it  were  not  for  the  unreasoning  organic  fear  of 
operation  which  is  still  so  general,  and  about  which 
something  will  be  said  in  the  next  chapter,  surely 
many  possessors  of  these  lamentably  disfigured  noses 
would  avail  themselves  of  surgical  relief. 

We  have  already  seen  that  the  surgeon  does  not 
fear  to  make  a  compound  fracture,  even  of  such 
large  bones  as  the  thigh-bone,  when  he  has  occasion. 
Plainly,  then,  it  is  possible  to  deal  with  the  nose 
quite  freely  in  cases  where  the  possessors  of  noses 
which  they  consider  redundant  in  their  bony  struc- 
ture, are  willing  to  undergo  an  operation  for  the 
sake  of  beauty.  And  the  converse  defect,  this  time 
literally  a  defect,  may  also  be  dealt  with.  Mr. 
Stephen  Paget  pointed  out  some  few  years  ago  the 
feasibility  of  increasing  the  bulk  and  correcting  the 
shape  of  a  nose  by  the  insertion  of  paraffin  in  suit- 
able quantity  and  of  appropriate   form  under  the 


254  SURGERY  AND  SOCIETY 

skin.  But,  as  we  shall  shortly  see,  the  modern 
surgery  of  the  nose  can  do  things  very  much  more 
worth  doing  than  any  modification  of  its  external 
form. 

The  number  and  variety  of  surgical  successes  in 
these  days  is  endless,  and  can  scarcely  be  kept  pace 
with,  unless  one  devotes  regular  reading  to  the  pur- 
pose. There  is  no  occasion,  however,  to  do  more 
in  these  pages  than  will  suffice  to  make  the  essential 
point  clear  to  the  reader.  At  a  recent  meeting  of 
surgeons  in  Berlin,  it  was  reported  that  the  trans- 
plantation of  an  entire  knee-joint  from  the  body  of 
a  person  just  deceased  to  that  of  a  patient  whose 
own  knee-joint  had  required  excision  for  tuberculo- 
sis, had  been  successfully  performed :  and  there  is  no 
end  to  the  possibilities  which  such  a  record  indicates. 

It  is  hardly  necessary  to  remind  the  reader  that 
such  an  operation  as  the  transplantation  of  a  joint 
could  only  be  performed  successfully  under  the 
strictest  and  most  efficient  Listerian  precautions  dur- 
ing every  stage  of  the  complicated  procedure  which 
would  evidently  be  necessitated.  One  has  only  to 
consider  the  possibilities  of  infection  in  such  a  case, 
and  the  consequences  of  failure  to  control  them,  in 
order  to  realise  what  Listerism  means  for  the  mod- 
ern surgeon.  All  the  rest  is  subsidiary:  daring,  me- 
chanical ingenuity,  dexterity,  swiftness,  anatomical 
knowledge  —  all  these  could  be  found  in  the  past, 
and  are  readily  available  to-day:  but  without  Lister- 
ism they  must  fail. 

Pity,  then,  the  unwisdom  and  the  miseries  of  man- 
kind, that  Greece  should  have  achieved  such  great 


SURGERY  AS  IT  IS  255 

things  in  science,  and  that  the  great  superstructure 
now  built  upon  those  foundations  should  have  had 
to  wait  for  so  many  centuries  of  disease  and  pain  and 
folly,  before  men  of  the  modern  time  —  in  them- 
selves by  no  means  superior  to  the  Greeks  —  could 
build  it.  What  a  lesson  for  the  enemies  of  science, 
and  the  champions  of  draped  or  naked  superstition ! 


CHAPTER  XI 

THE  RECORD  OF  A  CASE 

A  recent  surgical  experience  of  my  own  may 
justify  an  autobiographical  chapter  at  this  point  for 
several  reasons.  For  one  thing,  the  writing  of  the 
present  book  is,  in  part,  an  attempt  to  discharge 
my  debt  of  gratitude  to  surgery  for  a  very  great 
service  then  rendered  to  me.  Also  the  case  was  of 
a  very  common  kind,  which  has  been  suitably  treated 
by  surgeons  only  within  the  last  three  or  four  years ; 
and  the  operation  in  question  is  a  particularly  bril- 
liant and  notable  illustration  of  the  possibilities  of 
modern  Listerism.  Lastly,  my  record  of  the  facts 
may  serve  to  remove  the  fear  of  operation  from  the 
minds  of  some  who  would  be  very  much  better 
without  it.  I  shall  attempt  to  describe  my  feelings 
and  experiences  as  a  patient,  and  to  show  cause  for 
the  undoubted  fact  that,  being  asked  at  any  future 
date  to  undergo  a  surgical  operation,  I  should  do  so 
with  feelings  very  different  from  those  which  will 
shortly  fall  to  be  described.  No  doubt  there  are 
individuals  who  would  have  no  trepidation  before  a 
first  operation  or  a  tenth:  but  I  fancy  that  the  ma- 
jority of  my  readers  will  not  belong  to  that  minority. 
Like  a  great  many  other  people  I  had  all  my  life 
been  subject  to  colds,  which  were  usually  very  bad 

256 


THE  RECORD  OF  A  CASE  257 

ones,  and  lasted  a  long  time,  though  they  never 
interfered  with  my  work  or  play.  In  the  course  of 
my  thirty-first  winter,  however,  they  became  some- 
what worse,  one  running  into  another,  handkerchiefs 
being  incessantly  required,  and  new  symptoms  de- 
veloping themselves.  My  breathing  became  asth- 
matic after  exertion  or  on  exposure  to  fresh  cool  air, 
and  my  voice  began  to  be  persistently  hoarse.  This 
last  was,  of  course,  a  serious  matter  for  one  who, 
not  to  mention  private  efforts  at  what  he  calls  sing- 
ing, is  constantly  engaged  in  lecturing  and  public 
speaking.  The  customary  method  of  ignoring  all 
the  symptoms,  treating  them  with  contempt  and  ex- 
pecting them  to  disappear,  failed  in  this  case,  and 
after  coughing  all  the  way  to  Scotland  for  a  lecture 
tour,  I  consulted  a  specialist.  No  sooner  had  he 
looked  into  my  nose  than  he  declared  that  I  was  the 
possessor  of  a  deflected  nasal  septum.  This  is  to 
say  that  the  partition  between  the  nostrils,  instead  of 
being  strictly  in  the  middle  of  the  nose  and  in  one 
plane,  was  bent  or  buckled  to  one  side.  The  conse- 
quence was  that  one  nostril  was  too  narrow  and  the 
other  too  wide;  but,  more  seriously,  that  a  sort  of 
mechanical  ledge  was  present  in  the  nose  for  the 
reception  of  microbes.  Hence,  primarily,  my  lia- 
bility to  colds.  In  the  course  of  years  these  succes- 
sive colds  had  lowered  the  vitality  of  the  mucous 
lining  of  the  nose,  and  there  were  further  various 
hypertrophied  and  degenerated  portions  which 
acted  as  further  breeding-grounds  for  microbes. 
The  nasal  irritation  was  setting  up  a  congestion  of 
the  small  bronchi  in  the  lungs,  leading  to  asthma, 


258  SURGERY  AND  SOCIETY 

and  also  to  the  congestion  of  my  vocal  cords,  which 
I  had  never  had  in  my  life  before. 

It  seems  probable  that  deflection  of  the  nasal 
septum  is  not  unconnected  with  the  extremely  com- 
mon malady  of  adenoids,  from  which  I  had  suf- 
fered, and  which  I  had  had  well  removed  at  the 
age  of  seventeen.  This  deformity  or  maldevelop- 
ment  of  the  septum  is  a  very  common  thing,  and 
probably  a  considerable  number  of  persons  in  every 
hundred  suffer  from  a  greater  or  less  degree  of  it, 
and  they  tend  to  display  such  symptoms  as  I  did. 
Thus  it  is  likely  that  several  out  of  every  hundred 
of  my  readers  are  now  considering  what  is  also  their 
own  case.  It  need  hardly  be  said  that  the  deflec- 
tion is  permanent  and  its  effects  cumulative,  so  that 
its  victims  commonly  suffer  from  chronic  laryngitis 
and  are  permanently  hoarse  by  the  time  they  reach 
middle  life,  whilst  the  colds  and  the  liability  to  a 
form  of  nervous  asthma  further  lower  the  vitality 
and  must  certainly  shorten  life  on  the  average. 
Further,  the  removal  of  associated  adenoids,  or  even 
of  degenerated  ends  of  turbinal  bones,  is  only  a 
temporary  palliative. 

The  surgeon  simply  said  that  what  would  give  me 
most  relief  would  be  a  "  submucous  resection  of  the 
septum,"  an  operation  of  which  I  had  never  heard. 
It  is  most  unpleasant  to  be  talked  to  like  that.  One 
pulls  oneself  together  and  asks  what  the  operation 
amounts  to,  meanwhile  feeling  very  strongly  in- 
clined to  trust  in  something  else.  One  thinks  of 
accidents  in  the  way  of  sepsis,  of  deaths  from  an- 
aesthetics,  of  post-anaesthetic  sickness,    and  several 


THE  RECORD  OF  A  CASE  259 

other  such  things,  with  instantaneous  speed  and  keen 
imagination  —  which,  in  my  case,  had,  of  course, 
plenty  of  recollections  on  which  to  feed.  The  only 
alternative,  said  the  surgeon,  was  to  douche  the  nose 
daily  with  an  antiseptic  and  alkaline  lotion,  and  hope 
that  the  mucous  membrane  would  recover  its  tone 
—  but  the  chances  of  success  were  small. 

I  started  out  with  the  lotion,  but  was  not  en- 
couraged by  a  second  expert,  who  assured  me  that 
only  the  operation  would  be  of  any  use.  I  had  the 
advantage,  not  open  always  to  the  layman,  that  both 
of  these  men  were  my  personal  friends,  and  that 
I  could  rely  on  their  advice  as  absolutely  disinter- 
ested. But  I  gave  the  douching  a  fair  trial,  with 
complete  unsuccess:  the  long  process  of  deteriora- 
tion had  gone  too  far,  and  something  radical  was  re- 
quired—  the  more  especially  as  my  voice  became 
worse. 

So  I  decided  to  have  the  operation,  having  first 
ascertained  the  facts  of  it.  It  is  a  device  which  was 
introduced  only  three  or  four  years  ago  in  Vienna. 
Up  to  that  time  the  only  way  of  dealing  with  a  de- 
flected septum  was  to  break  it  by  sheer  force  and 
then  set  it  up  straight  in  splints.  The  results  were 
very  poor,  to  say  nothing  of  the  prolonged  pain  and 
discomfort  which  the  patient  had  to  undergo.  A 
leading  objection  was  that  the  mucous  membrane 
of  the  nose  was  always  necessarily  injured  by  the 
blow  which  was  employed  to  break  the  septum,  and 
that,  in  the  course  of  healing,  the  beautiful  cells, 
with  fine  living  "  cilia  " — which  is  Latin  for  "  eye- 
lashes " — that  kept  the  surface  clean  and  clear,  and 


26o  SURGERY  AND  SOCIETY 

the  mucous  cells  which  kept  it  moist,  were  replaced 
by  flat  epithelial  cells,  which  became  dry  and  the 
seat  of  crusts.  These  crusts  were  a  nuisance  when 
present,  and  the  nose  bled  when  they  were  removed. 
The  exquisitely  adapted  normal  epithelium  or  cell- 
lining  of  the  nose  cannot  be  successfully  replaced  by 
anything  else.  So  as  a  rule  patients  suffering  from 
this  exceedingly  common  defect  simply  endured  the 
consequences  without  substantial  help  from  medicine 
or  surgery. 

So  the  matter  stood  until  the  Viennese  rhinologist 
invented  an'  operation  which  is  highly  typical  of 
what  modern  surgery  contrives  and  achieves.  This 
is  the  operation  of  "  submucous  resection  "  of  the 
septum,  and  the  point  of  it  is  that  the  surgeon  makes 
a  large  flap  of  the  mucous  membrane,  turns  the  flap 
up,  and  then  proceeds  as  he  will,  until  he  is  done, 
when  he  restores  the  flap  to  its  place,  securing  it 
with  a  single  stitch,  and  leaves  the  patient  with  the 
mucous  lining  of  his  nose  intact,  so  that  it  is  not 
liable  to  become  dry  or  crusted  or  hemorrhagic. 
As  for  the  intervening  process  of  "  resection/'  which 
is  thus  performed  underneath  the  mucous  membrane 
and  hence  called  "  submucous,"  it  is  no  less  than  the 
bodily  removal  of  the  nasal  septum  in  its  entirety, 
which  is  vastly  better  than  breaking  or  leaving  it, 
but  of  course  involves  much  more  interference  and 
damage.  This  septum  is  composed  partly  of  carti- 
lage and  partly  of  bone,  especially  in  its  upper  por- 
tion. The  bony  septum  is  largely  composed  of 
parts  of  two  of  the  bones  which  form  the  base  of  the 
skull.     All  this  the  surgeon  removes,  together  with 


THE  RECORD  OF  A  CASE  261 

a  wide  and  strong  bony  crest  from  the  upper  jaw. 
For  this  purpose  he  requires  hammer  and  chisel, 
various  gouges,  a  remarkable  American  knife,  hav- 
ing a  very  short,  balanced  blade  at  the  end  of  a  han- 
dle, which  is  so  made  that  it  will  cut  in  any  direction 
towards  which  the  surgeon  presses,  and  a  variety 
of  other  instruments.  It  need  hardly  be  said  that 
the  consequences  of  infection  by  microbes  in  the 
course  of  such  an  operation  would  be  horrible,  the 
bones  and  air-cells  at  the  base  of  the  skull,  the  upper 
jaw  and  many  other  structures  all  being  open  to  in- 
fection. Evidently  no  surgeon  could  contemplate 
such  a  procedure  for  anything  short  of  desperate 
need,  unless  he  could  count  on  the  perfection  of  his 
Listerian  methods:  but  there  are  no  other  means  of 
radical  relief  open  to  the  many  persons  who  are 
afflicted  as  I  was. 

Of  course  one  went  to  a  nursing  home  where  the 
proper  conditions  were  available,  as  they  are  not  in 
any  private  house,  be  it  a  palace.  I  wanted  to  hear 
Mdlle.  Destinn  at  Covent  Garden  on  the  night  be- 
fore, there  being  always  a  speculative  element,  how- 
ever small,  in  these  matters,  but  was  instead  com- 
pelled to  go  to  bed  at  nine,  as  the  anaesthetist 
preferred  his  patient  to  have  a  quiet  evening.  No 
food  of  any  kind  was  allowed  after  ten  o'clock. 
The  lay  reader  may  be  strongly  advised  to  acquiesce 
intelligently  and  heartily  in  all  such  instructions  for 
himself  or  for  a  relative  or  friend  before  a  surgical 
operation.  A  quiet  preceding  day,  with  bed  at  an 
early  hour,  nothing  but  a  glass  of  milk  later  than 
ten    o'clock  —  the    preceding    dinner    having    been 


262  SURGERY  AND  SOCIETY 

light  and  simple  —  a  dose  of  an  aperient,  however 
unfamiliar:  these  are  some  of  the  means  which  im- 
mensely simplify  and  safeguard  the  duty  of  the  an- 
aesthetist, and  they  greatly  promote  the  patient's 
comfort  after  the  operation.  In  my  case  there  was 
little  more  to  consider :  but  in  many  cases  the  fatigue 
involved  in  taking  an  anaesthetic  badly,  and  in  post- 
anaesthetic  sickness,  is  much  more  serious  than  mere 
discomfort,  whilst  the  movements  involved  may  be 
gravely  deleterious  from  the  surgical  point  of  view. 
Let  us  therefore  be  strongly  convinced  that  due 
preparation  of  mind  and  body  for  operation  is  a 
most  important  and  profitable  proceeding.  Of 
course  in  the  majority  of  cases  there  is  the  added 
need,  in  some  ways  much  more  important  than  any 
of  the  foregoing,  that  the  patient's  skin  at  the  site 
of  operation  shall  be  prepared,  and  to  do  this  thor- 
oughly, especially  in  preparation  for  an  aseptic 
operation,  may  be  a  matter  of  forty-eight  hours. 
Here  again  an  intelligent  laity  will  do  well  to  accept 
the  surgical  estimate  of  the  importance  of  this 
ritual. 

It  is  to  be  noted  that  serious  disasters,  not  short 
of  death,  have  followed  the  failure  of  relatives  to 
appreciate  the  importance  of  these  matters.  It  is 
bad  enough  for  a  mother  surreptitiously  to  give  her 
boy  an  apple,  less  than  twenty-four  hours  after  an 
operation  for  appendicitis,  as  I  have  known  done; 
but  it  may  be  much  worse  to  fear  that  one's  friend 
is  being  starved,  and  give  him  or  her  solid  food 
shortly  before  an  operation.  Even  if  one  could 
guarantee  that  the  stomach  would  digest  the  food, 


THE  RECORD  OF.  A  CASE  263 

there  would  still  be  serious  objections  to  it:  but  the 
stomach  of  a  person  who  knows  that  he  is  about  to 
undergo  a  surgical  operation  will  very  likely  be 
thrown  out  of  gear  by  the  notion  of  impending 
danger,  and  thus  the  case  is  still  further  compli- 
cated. And  nothing  can  be  more  heart-breaking 
for  the  anaesthetist  who  has  given  careful  and  strin- 
gent orders,  than  to  have  his  patient  sick  under  the 
anaesthetic,  and  find  that  the  stomach,  which  should 
be  empty,  contains  food,  perhaps  in  solid  lumps, 
which  involves  the  danger  of  immediate  choking  or, 
scarcely  less  serious,  the  aspiration  into  the  air-chan- 
nels of  particles  of  food  which  subsequently  set  up  a 
post-operative  pneumonia.  The  public  cannot  be 
expected  to  know  these  things  without  being  told, 
and  in  these  days  the  public  cannot  be  expected  to 
follow  professional  directions  as  if  they  were  in- 
spired and  unquestionable.  Therefore  I  have  set 
down  briefly  some  of  the  reasons  why  it  is  worth 
while  to  obey  orders  in  the  instance  under  discus- 
sion. I  have  every  personal  reason  to  know  that 
they  are  worth  while,  having  seen  the  effects  of 
obedience  and  disobedience,  and  having  experienced 
the  quite  remarkable  advantages  which  follow  from 
the  observance  of  the  best  expert  indications  in  the 
matter  of  anaesthesia. 

To  resume  the  narrative :  I  went  duly  to  bed  at 
an  hour  unprecedented  since  childhood,  and  slept 
quite  well.  In  the  morning,  breakfastless,  I  sat  up 
in  a  chair  for  half  an  hour  whilst  my  nostrils  were 
painted  with  cocaine  and  adrenalin,  those  remark- 
able drugs  which  contract  blood-vessels  and,  in  such 


264  SURGERY  AND  SOCIETY 

cases  as  this,  are  invaluable  to  the  surgeon,  who  is 
practically  able  to  perform  an  operation  in  a  part 
of  the  body  peculiarly  well-supplied  with  blood,  as 
if  there  were  no  such  thing  as  blood  at  all.  Then  I 
walked  into  the  next  room,  and  sat  in  a  chair,  and 
was  shown  the  various  novel  instruments  to  be  em- 
ployed, and  found  it  difficult  to  be  nervous  —  as  I 
would  beg  the  lay  reader,  or  indeed  any  reader  who 
has  not  been  through  the  experience,  to  observe  — 
because  no  one  else  was.  They  were  cheery,  com- 
petent, prepared,  confident,  accustomed.  Only  sub- 
sequently did  one  realise  the  immense  value  to  the 
patient  of  this  psychological  attitude  on  the  part  of 
those  who  surrounded  him.  The  whole  affair  was 
so  palpably  customary,  straightforward,  assured,  in 
their  eyes,  that  one  felt  that  any  display  or  even  any 
internal  feeling  of  doubt  or  glumness  would  be  bad 
manners  and  out  of  the  question.  Further,  I  had 
the  advantage  of  having  watched  the  same  surgeon 
and  the  same  anaesthetist  at  work  in  a  most  finished 
and  brilliant  affair  of  some  ninety  seconds  when  re- 
moving adenoids  from  my  small  daughter :  and  that, 
no  doubt,  was  a  help.  Anyhow,  I  wish  to  insist  that 
the  whole  of  the  preliminary  proceedings  were  ut- 
terly different  in  anticipation  and  in  fact;  and  I  hope 
to  comfort  a  few  readers,  when  their  turn  comes, 
by  this  testimony.  Before  the  time  came,  one  pic- 
tured the  preceding  night,  the  entry  into  the  oper- 
ating-room, and  so  forth,  as  very  formidable  and 
terrifying  experiences.  They  were  nothing  of  the 
sort.  When  the  time  came,  they  were  interesting, 
dramatic  and  somewhat  amusing,  rather  than  any- 


THE  RECORD  OF  A  CASE  265 

thing  else;  and,  as  I  say,  one  could  never  again  in- 
dulge such  anticipations  after  this  experience. 

One  could  not  really  fear  the  anaesthetic,  even 
though  in  this  operation  it  has  to  be  taken  whilst  one 
sits  or  is  propped  in  a  chair.  I  knew  my  alimentary 
canal  was  empty,  and  that  I  was  a  lifelong  teetotal- 
ler, and  could  at  any  time  run  ten  miles.  Three 
seconds  before  the  mask  was  applied  to  my  face, 
my  heart  began  to  make  its  action  felt,  and  my  last 
thought  was  of  Prof.  James's  theory  that  we  feel 
afraid  because  the  heart  palpitates,  rather  than 
that  the  heart  palpitates  because  we  are  afraid. 
My  verdict  was  then,  and  still  is,  that  James  was 
wrong:  but  that  the  palpitation  accentuates  the 
fear.  In  less  than  five  seconds  more  I  was 
unconscious.  My  admirable  friends  had  sent  me 
off  with  nitrous  oxide  or  laughing-gas,  such  as  den- 
tists use,  and  continued  the  proceedings  with  chlo- 
roform. 

There  can  be  no  doubt  that  this  is  the  right  pro- 
cedure. Ten  years  ago  they  were  still  using,  in 
Edinburgh,  the  "  open  method "  of  administering 
chloroform  which  was  the  original  method  employed 
there  by  Sir  James  Simpson,  and  I  have  vivid  rec- 
ollections of  long  periods  during  which  the  patient 
slowly  relapsed  into  unconsciousness,  with  no  con- 
tinuous and  even  passage  thereto,  and  with  all  man- 
ner of  speech  and  struggling,  none  the  more  pleasant 
or  less  pronounced  for  the  alcoholic  habits  of  many 
of  the  patients.  All  this  kind  of  thing  uses  up  the 
patient's  strength,  discomposes  his  circulation  and 
respiration,   greatly  predisposes  to   chloroform-sick- 


266  SURGERY  AND  SOCIETY 

ness  during  and  after  the  operation,  with  its  at- 
tendant risks  and  involves  the  inhalation  of  far  more 
of  the  drug  than  would  otherwise  be  necessary. 
Further,  this  prolonged  period  of  anxious  strug- 
gling, "  going  under  "  and  coming  out,  and  being 
reassured  by  the  administrator,  and  told  to  take  long 
breaths  —  must  all  be  very  unpleasant  for  the  pa- 
tient. No  doubt  many  sensible,  non-alcoholic,  non- 
nervous  patients,  having  the  drug  carefully  adminis- 
tered by  the  open  method,  will  go  evenly  under,  but 
even  so  this  cannot  compare  with  the  initial  use  of 
nitrous  oxide,  which  sends  the  patient  off  with  his 
third  or  fourth  inspiration,  and  does  so  with  abso- 
lute safety.  Nothing  has  struck  me  more  than  the 
contrast  between  this  experience  of  my  own  in  19 10, 
and  what  one  daily  observed  and  participated  in, 
from  another  point  of  view,  in  Edinburgh  only  ten 
years  earlier.  And  the  practically  instantaneous 
loss  of  consciousness  was  no  less  advantageous  than 
the  subsequent  consequences  of  this  modern  method 
of  inducing  anaesthesia. 

During  the  operation,  which  lasted  for  about  half 
an  hour,  and  was  conducted  in  a  chair,  which  in- 
volves much  more  strain  upon  the  heart  than  the 
lying  position,  and  would  be  vastly  more  incon- 
venient if  the  patient  were  sick,  this  particular  pa- 
tient gave  no  anxiety  at  all,  but  breathed  as  teetotal- 
lers do  under  anaesthetics,  and  had  no  gastric 
disturbance,  having  been  duly  prepared  in  the 
fashion  described.  I  know  nothing  whatever  from 
my  third  breath,  or  so,  of  the  anaesthetic,  to  the 
moment  when  I  found  myself  lying  on  my  side  in 


THE  RECORD  OF  A  CASE  267 

bed,  and  heard  a  nurse's  voice  saying  that  it  was  all 
over.  And  now  came  the  full  virtue  of  all  the  skill 
and  forethought  to  which  I  had  been  subjected.  I 
never  had  a  qualm,  my  head  was  perfectly  clear  and 
did  not  even  ache,  and  yet  I  had  been  under  chloro- 
form for  half  an  hour,  and  had  had  chisels  and 
things  knocking  about  at  the  base  of  my  cranium. 
In  three  hours  I  was  scribbling  a  letter,  and  not  long 
thereafter  was  swallowing  a  cup  of  unsweetened  tea. 
I  had  much  feared  the  subsequent  discomfort  and 
pain.  Pain  there  was  none,  and  the  discomfort  went 
for  nothing  against  the  satisfaction  of  knowing  that 
the  operation  was  over.  This,  one  supposes,  must 
be  the  common  experience:  the  anxiety  and  appre- 
hension are  gone  with  returning  consciousness,  and 
anything  to  be  borne  thereafter  is  child's  play.  I 
had  not  a  wink  of  sleep  that  night,  nor  the  next, 
owing  to  sheer  excitement;  and  as  there  never  was 
a  better  sleeper,  I  am  certain  that  in  other  circum- 
stances this  would  have  been  a  most  grievous  and 
almost  unendurable  affliction.  But  the  blessed 
thought  that  the  thing  was  done  made  the  sleepless 
hours  easy.  My  evidence  certainly  is  that,  taking 
the  ordeal  from  the  first  to  the  last,  the  anticipation 
was  by  far  the  worst  part  of  it.  Doubtless  things 
would  have  been  very  different  in  the  absence  of 
skilled  preparation,  perfect  administration  of  the 
rightly  prescribed  anaesthetic,  and  unfailing  aseptic 
technique  on  the  part  of  the  surgeon :  but  my  present 
business  is  to  insist  that,  given  these  conditions,  such 
an  operation  is  not  really  a  thing  to  be  feared  as  one 
inclines  to  fear  it.     I  could  not  possibly  feel  arty- 


268  SURGERY  AND  SOCIETY 

thing  more  acute  than  annoyance  and  fear  of  bore- 
dom if  I  had  to  undergo  the  same  operation  again, 
and  the  reader  may  be  assured  that  very  much  more 
serious  operations  may  be  undergone,  in  these  days, 
with  little,  if  any,  more  "  suffering "  than  I  was 
called  upon  to  endure. 

But  before  we  extract  the  moral  from  this  tale 
let  the  sequel  be  duly  told.  I  was  allowed  to  go 
home  in  three  days,  and  was  absurdly  "  slack  "  for 
another  four  —  quite  content  to  lie  about  and  read 
in  the  garden,  just  as  if  I  had  contracted  acute  "  pot- 
terer's  rot."  On  the  seventh  day,  my  appetite  for 
things  returned  and  I  went  to  Lord's  to  see  a 
cricket  match  —  having  been  previously  warned 
against  infectious  dust.  Of  course  I  caught  a  cold, 
and  of  course  it  was  a  very  bad  one.  But  when  I 
remember  the  colds  of  the  past,  I  think  I  may  safely 
boast  that  it  was  my  last.  I  have  had  one  cold  in 
eleven  months  since  then,  having  travelled  all  over 
the  country  to  speak,  by  day  and  night,  hatless  and 
very  lightly  clothed.  It  was  a  trivial  cold,  which 
would  have  been,  a  year  before,  too  trifling  an  ag- 
gravation of  my  ordinary  state  to  notice.  The  asth- 
matic symptoms  slowly  but  certainly  disappeared, 
beginning  to  do  so  at  once,  and  taking  their  depart- 
ure altogether  after  about  six  months.  This  was 
the  period  for  which,  I  had  been  told,  one  must  wait 
for  the  full  benefit  of  the  operation.  By  that  time 
my  voice  had  perfectly  recovered,  and  the  vocal 
cords  were  found  to  be  normal:  to  say  nothing  of 
the  disappearance  of  a  hideous  nasal  tone  which  had 
latterly  become   unavoidable.     Some   eight  months 


THE  RECORD  OF  A  CASE  269 

after  the  operation  I  was  examined  for  life  insur- 
ance, and  found  in  first-class  physical  condition  in 
every  respect.  But  before  the  operation  I  had  been 
advised  to  have  my  sputum  examined  for  tubercle 
bacilli:  and  certainly  no  office  would  have  accepted 
my  life  at  that  time,  considering  the  obvious  condi- 
tion of  my  nose,  the  sound  of  my  voice,  and  the 
whistlings  in  my  chest. 

Trivial  though  the  whole  trouble  might  be  reck- 
oned, it  was  of  the  first  importance  to  myself,  threat- 
ening my  work  and  pleasure,  and  involving  organs 
which  might  later  have  been  very  readily  attacked 
in  consequence  by  the  tubercle  bacillus.  The  serv- 
ice wrought  me  by  Listerian  surgery  was  complete, 
it  was  safe,  it  was  final,  it  was  irreplaceable,  and  it 
was  highly  educative. 

The  reader  will  do  well  to  profit  by  my  experi- 
ence. Operations  are  not  to  be  feared  as  we  are 
apt  to  fear  them.  The  patient  recovering  from  an 
anaesthetic  properly  administered  does  not  feel 
nearly  so  bad  as  he  appears  to  the  onlooker:  he 
probably  feels  immensely  pleased  with  himself,  and 
very  naturally  so.  Yet  my  surgeons  told  me  of 
various  cases  where,  for  instance,  a  professional 
tenor,  whose  voice  was  threatened,  and  was  in  any 
case  never  to  be  counted  upon,  owing  to  his  liability 
to  colds,  did  not  dare  to  have  his  deflected  septum 
removed,  because  a  surgical  operation  was  in  his 
eyes  a  desperate  matter.  He  was  a  sample  of  a 
very  common  type.  Numerous  cases  are  always  oc- 
curring where  people  refuse  altogether  operations 
which  would  greatly  serve  them,  and  for  which  no 


270  SURGERY  AND  SOCIETY 

substitute  exists,  or  where  they  postpone  inevitable 
operations  until  it  is  too  late.  Surgeons  have  to 
reckon  not  only  with  patients  but  with  patients' 
friends;  not  only  with  the  patient's  own  fear,  but 
with  the  fear  which  his  friends  communicate  to  him. 
Thus  operation  is  refused,  or  is  unduly  or  disas- 
trously delayed ;  or  when  the  patient  does  undergo  it 
he  prejudices  his  chances  by  fear,  which  prevents 
him  from  sleeping  before  it,  and  disturbs  the  taking 
of  the  anaesthetic. 

I  would  incline  to  say  that  not  even  the  witness- 
ing of  many  operations  will  suffice  as  first-hand  edu- 
cation; one  must  undergo  an  operation  oneself, 
which  is  a  most  illuminating  and  entirely  different 
experience.  Short  of  that,  one  must  be  instructed 
by  someone  who  has  the  necessary  experience,  and 
it  is  that  instruction  which  I  now  offer  to  the  reader. 
Let  him  consider  the  record  of  this  case,  and  recon- 
sider his  attitude  towards  operations  both  on  his  ac- 
count and  on  account  of  any  whom  he  may  love. 
And  let  it  not  be  to  his  danger  or  discredit  or  lasting 
regret  that  he  delayed  or  refused  operation  on  him- 
self or  another,  when  with  more  wisdom  he  would 
have  acquiesced  not  so  fearfully. 

Lastly,  let  us  observe  how  very  valuable  surgery 
is  in  such  a  case  as  this,  and  how  entirely  irreplace- 
able it  is.  Practically  all  the  victims  of  deflected 
nasal  septa  hitherto  have  been  helpless  —  voice, 
comfort,  health  have  in  greater  or  less  degree  been 
destroyed,  and  there  was  no  remedy.  The  most 
skilful  and  patient  medication  fails:  surgery,  if  it  be 
sufficiently    daring    and    skilful,    succeeds    wholly. 


THE  RECORD  OF  A  CASE  271 

The  newspapers  contain  advertisements  of  remedies 
which  are  to  relieve  nasal  catarrh  and  its  conse- 
quences, without  operation;  and  such  advertise- 
ments, together  with  the  rarity  of  first-class  sur- 
geons, and  the  public  fear  of  operations,  and 
carelessness  in  seeking  proper  diagnosis  for  such 
things  as  cold-in-the-head  —  mean  that  probably  not 
one  in  many  thousands  who  really  need  this  opera- 
tion and  who  will  get  no  relief  without  it,  ever  ob- 
tains the  relief  I  did.  It  is  time  we  honoured  and 
recognised  and  made  available  for  ourselves  and 
others  boons  to  human  life  of  so  high  an  order  as 
this;  and  if  only  one  reader,  in  consequence  of  this 
chapter,  profits  as  I  did,  it  will  have  been  well  worth 
writing.     But  I  hope  there  may  be  many. 


CHAPTER  XII 

SURGERY  AND  ALCOHOL 

It  may  be  stated  in  general  terms  that,  ever  since 
time  began,  man  has  employed  for  medical  purposes 
all  the  substances  known  to  him  which  had  a  marked 
influence  upon  the  human  body  or  any  of  its  func- 
tions. Ignorance  has  no  resort  but  to  grasp  for  sal- 
vation in  the  dark  at  whatever  promises  a  hold. 
Thus  one  remembers  a  medical  student  saying  that 
he  intended,  when  he  got  the  chance,  to  begin  at  the 
beginning  of  the  alphabet  and  test  every  known  drug 
until  he  found  one  —  which  must  surely  exist  — 
that  should  cure  consumption.  That  is  the  method 
of  ignorance  in  matters  of  disease,  which  has  pre- 
vailed until  almost  our  own  time.  It  is  therefore 
natural  that  alcohol,  the  most  easily  obtainable  and 
widely  known  of  all  drugs,  should  have  been  used  in 
disease  as  in  health  by  mankind  in  all  times  and 
places  of  which  we  have  anything  like  adequate 
record.  In  the  judgment  of  those  who  directly  con- 
cern themselves  with  the  scientific  study  of  alcohol 
to-day  this  unholy  alliance  between  alcohol  and  the 
art  of  healing  has  been  condemned  root  and  branch, 
in  principle  and  in  detail,  by  modern  knowledge. 
Our  concern  here  is  with  surgery  alone,  and  though 
it  is  doubtless  in  non-surgical  affections  that  alco- 
hol has  been  most  largely  abused,  yet  the  case  which 

272 


SURGERY  AND  ALCOHOL  273 

stands  in  relation  to  surgery  is  of  the  utmost  interest 
historically  and  of  the  very  highest  importance  in 
its  bearing  upon  the  best  surgical  practice  to-day, 
and  especially  upon  the  difference  between  the  best 
and  the  second  best. 

Alcohol  belongs  to  the  class  of  what  are  called  by 
toxicologists  the  protoplasmic  poisons,  together  with 
a  considerable  number  of  other  compounds,  and  also 
certain  elements,  such  as  arsenic  and  phosphorus. 
It  appears  to  be  essentially  of  the  nature  of  a  poison 
to  all  forms  of  living  matter,  animal  or  vegetable. 
It  is  therefore  necessarily  an  antiseptic,  and  we  have 
historical  evidence,  of  which  only  one  instance  need 
be  cited,  that  what  we  now  recognise  to  be  the  anti- 
septic property  of  alcohol  has  long  been  known. 
The  instance  will  suggest  to  us  the  conclusion  at  which 
we  shall  arrive  when  the  argument  has  been  com- 
pleted. It  is  that  alcohol  is  of  great  value  exter- 
nally in  surgery  but  works  great  injury  when  used 
internally. 

In  the  parable  of  the  Good  Samaritan  it  is  de- 
scribed how  a  wounded  man  was  found  by  a  kind 
traveller  who,  though  of  a  hostile  sect,  "  had  com- 
passion on  him,  and  went  to  him  and  bound  up  his 
wounds,  pouring  in  oil  and  wine."  *  I  am  not  pre- 
pared to  choose  between  orthodox  and  heterodox 
explanations;  but  the  fact  is  that  in  this  account, 
meant  to  illustrate  right  and  kindly  treatment,  alco- 
hol is  described  as  having  been  used  as  an  external 
antiseptic,  but  the  Good  Samaritan  is  not  described 
as  having  administered  it  internally.  That  point 
1  St.  Luke  x.  30-37. 


274  SURGERY  AND  SOCIETY 

need  not  here  be  pressed,  save  only  to  say  in  passing 
that  if  the  Good  Samaritan,  seeking  to  do  his  very 
best  for  his  patient  and  having  alcohol  at  his  hand, 
used  it  to  cleanse  the  wounds,  but  deliberately  re- 
frained from  employing  it  internally,  his  surgical 
practice  was  in  so  far  better  than  any  but  the  very 
best  in  our  own  time.  The  modern  surgeon  would 
not  employ  any  sweet  oil  in  this  fashion,  knowing  as 
he  does  that  for  various  physico-chemical  reasons, 
hitherto  imperfectly  elucidated,  such  oils,  themselves 
very  far  from  antiseptic,  interfere  with  the  action  of 
antiseptics.  Various  bacteria  can  grow  in  carbolic 
oil,  for  instance.  Our  concern  here,  however,  is  not 
to  pronounce  upon  what  was  doubtless  narrated  as 
indicative  of  the  best  surgery  of  the  time,  but  merely 
to  note  that  the  use  of  alcohol  as  an  antiseptic  was 
known  in  Palestine  in  the  time  of  Christ;  as  doubt- 
less in  many  other  parts  of  the  world  at  that  time 
and  before  it.  A  survey  of  the  whole  evidence 
available  would  convince  anyone  that  the  practice, 
based  upon  genuine  observation,  was,  we  need  not 
doubt,  justified  by  results.  There  are  good  reasons, 
also,  for  the  employment  of  oil,  though  it  has  the 
disadvantages  that  have  been  named,  and  it  is  only 
just  in  our  own  day  that  we  are  learning  how  to 
obtain  the  value  of  oil  with  due  deference  to  the 
antiseptic  principle.  At  any  rate,  it  is  of  interest, 
certainly  historical  and  possibly  theological,  to  ob- 
serve what  the  practice  of  the  Good  Samaritan  in 
the  parable  was.  Having  wine,  anyone  nowadays 
playing  this  part  would  begin  by  administering  it 
internally,  and  wtnild  be  thought  miserly  and  cruel 


SURGERY  AND  ALCOHOL  275 

if  he  did  not.  The  internal  administration  of  an 
alcoholic  drink  is  the  very  first  thing  that  would  be 
thought  of  and  done  by  ninety-nine  persons  out  of 
a  hundred  in  such  a  case.  The  verdict  of  modern 
experimental  toxicology  is  that  they  would  all  be 
wrong,  and  the  Good  Samaritan,  whose  external  use 
of  alcohol  is  mentioned,  but  to  whom  the  Inventor 
of  the  parable,  though  desirous  of  describing  his 
deed  as  skilful  and  generous,  did  not  attribute  its 
internal  administration,  was  right. 

At  the  present  time  the  surgeon  finds  in  alcohol, 
under  certain  conditions,  a  most  valuable  antiseptic 
agent.  The  conditions,  however,  are  worth  noting. 
The  substance  is  a  protoplasmic  poison,  as  indeed 
most  antiseptics  are.  When  it  is  applied  to  a 
wound,  therefore,  the  fact  that  it  is  injurious  to  mi- 
crobes is  always  complicated  by  the  further  fact 
that  it  is  also  injurious  to  the  tissue  cells  of  the  part, 
upon  whose  vitality  the  patient  depends  for  heal- 
ing. Thus  in  no  circumstances  is  alcohol  now  poured 
into  an  aseptic  wound.  On  the  other  hand,  the  use 
of  an  alcoholic  soap  to  remove  the  outer  infected 
layers  of  the  skin  —  as,  for  instance,  the  skin  of  a 
surgeon's  hands  prior  to  operation  —  is  very  valu- 
able; and  the  same  soap  may  be  applied  to  the  un- 
broken skin  of  the  patient  before  any  operation. 
The  alcohol  is  here  used  as  a  valuable  cleansing  and 
antiseptic  agent,  without,  however,  reaching  the  liv- 
ing cells  of  deeper  layers,  which  it  would  of  course 
injure.  Further,  the  antiseptic  and  cleansing  prop- 
erties of  alcohol  may  be  employed  in  the  preserva- 
tion and  protection  of  various  instruments  which  the 


276  SURGERY  AND  SOCIETY 

surgeon  has  occasion  to  employ.  Everyone  is  fa- 
miliar with  various  forms  in  which  alcohol  exercises 
its  property  of  a  cleanser,  but  modern  investigation 
has  greatly  enhanced  our  appreciation  of  its  cleans- 
ing properties  by  showing  that  it  is  a  powerful  anti- 
septic. 

It  may  be  remarked  in  passing  that  surgeons  and 
bacteriologists  have  not  yet  interested  themselves 
to  any  appreciable  extent  in  the  vastly  interesting 
question,  Why  are  antiseptics  antiseptics? 

Microbes  are  perhaps  the  very  simplest  forms  of 
life  now  extant.  To  study  the  conditions  under 
which  they  are  killed  is,  by  no  means  indirectly,  to 
study  the  conditions  under  which  life  at  its  simplest 
may  be  maintained.  The  ultimate  solution  of  the 
problem  of  life  will  be  reached  through  physico- 
chemical  inquiry  along  the  lines  already  roughly 
sketched  out  by  one  or  two  contemporary  students. 
In  the  particular  case  of  alcohol,  it  seems  clear  that 
its  antiseptic  property  in  concentrated  solutions, 
which  exercise  an  actually  and  immediately  lethal 
action  upon  microbes,  depends  primarily  upon  the 
fact  that  it  has  the  power  of  coagulating  or  render- 
ing solid  some,  at  any  rate,  of  the  albumins  or  pro- 
teins which  occur  in  fluid,  and  therefore  labile,  form 
in  all  living  cells. 

But  this  fatal  coagulation  of  albumin  only  fol- 
lows from  the  application  of  alcohol  in  concentrated 
form.  In  weaker  solutions  alcohol  retards  or  de- 
stroys the  life  of  microbes  or  of  living  cells  gener- 
ally, probably  by  an  action  which  is  well  illustrated 
when  alcohol  is  taken  into  our  blood.     The  proc- 


SURGERY  AND  ALCOHOL  277 

esses  of  oxidation  or  combustion  upon  which  all 
life  depends  are  retarded.  As  this  action  concerns 
not  only  "  germs  "  but  germ-cells,  as  I  suspect,  it 
may  be  carefully  considered  here. 

In  the  influence  of  alcohol  as  a  coagulator  of  al- 
bumin we  have  the  crude  or  "  contact "  action  of 
the  drug.  It  depends  upon  a  high  degree  of  con- 
centration, and  is  thus  conspicuously  inapplicable  to, 
for  instance,  the  case  of  a  septic  dyspepsia.  The 
patient  may  take  alcohol  in  such  cases  —  he  usually 
does,  and  they  are  usually  its  consequence  —  but  he 
does  not  disinfect  the  gastric  contents,  for  the  alco- 
hol, taken  even  in  the  extremist  concentration  which 
the  mouth  will  tolerate,  is  at  once  diluted  by  the 
gastric  contents.  Further,  even  if  the  stomach 
were  empty  the  alcohol  would  speedily  be  diluted, 
for  this  substance  has  an  intense  physico-chemical 
affinity  for  water,  which  it  will  draw  to  itself  from 
any  available  quarter.  This  action  is  so  rapid  and 
powerful  that  alcohol  cannot  be  used  as  a  local 
caustic  —  it  does  not  kill  outright  the  cells  of  any 
tissue  to  which  it  may  be  applied. 

Of  far  more  significance  is  the  fact  that  alcohol 
has  an  inhibitory  or  arrestive  action  upon  ferments. 
As  we  have  already  seen,  the  activities  of  microbes 
are  affected  through  the  ferments  which  they  pro- 
duce. If  these  ferments  or  toxins  be  interfered 
with,  the  injurious  action  will  be  arrested.  But 
more:  all  vital  processes  are  dependent,  we  now 
believe,  upon  fermentation.  This  is  true  of  all  liv- 
ing cells,  whether  "  germs  "  or  germ-cells.  Here, 
it  may  be  suggested,  is  the  outline  of  a  key  to  the 


278  SURGERY  AND  SOCIETY 

behaviour  of  alcohol  when  germ-cells  are  exposed 
to  its  action,  as  it  circulates  in  the  blood  of  a  future 
parent.  The  factors  in  the  germ-cell  are  really 
ferments,  or  the  antecedents  of  ferments,  and  to 
expose  them  to  alcohol,  we  may  imagine  as  a  sug- 
gestive hypothesis,  is  evidently  to  threaten  the  de- 
velopment of  the  future  individual.  The  fact  is 
proved :  and  this  may  suggest  the  interpretation. 

A  digression  which  refers  to  so  important  a 
parallel  may  possibly  be  pardoned.  At  least  it  will 
suffice  to  show  that  the  relations  of  alcohol  to  vital 
processes  are  very  much  more  than  those  of  its 
14  contact "  action.  It  is  probable  that  in  any  dilu- 
tion whatever  it  retards  the  processes  of  fermenta- 
tion and  is  accordingly  negligible  nowhere.  Its 
well-known  action  in  preventing  the  blood  from  giv- 
ing up  its  oxygen,  which  has  been  customarily  de- 
scribed as  "  increasing  the  stability  of  the  oxy- 
hemoglobin of  the  blood,"  really  depends,  no  doubt, 
upon  this  interference  with  the  processes  of  fermen- 
tation which  are  involved  in  the  decomposition  of 
oxy-haemoglobin.  The  consideration  of  these  mat- 
ters will  help  us  understand  what  is  of  practical  im- 
portance and  interest  —  the  internal  action  of  alcohol 
in  relation  to  the  vital  processes  of  repair  and  de- 
fence against  the  attacks  of  microbes,  which  are  at 
the  foundation  of  all  surgery.  Here  is  a  question 
which  concerns  the  surgeon  and  all  his  patients,  actual 
or  possible  and,  as  we  shall  see,  it  is  like  not  a  few 
others  —  as  that  of  the  relation  between  the  earth 
and  the  sun  —  in  that  the  present  returns  an  answer 
directly  contrary  to  that  of  the  past  because  it  de- 


SURGERY  AND  ALCOHOL  279 

pends  upon  a  deeper  analysis  than  any  formerly  pos- 
sible. 

But  before  we  discuss  this  reversal  of  opinion  we 
may  begin  with  an  earlier  consideration  from  the 
surgeon's  point  of  view.  In  so  far  as  he  is  an  opera- 
tor, his  first  concern  must  necessarily  be  the  charac- 
ter of  his  patient  as  a  subject  for  the  administration 
of  an  anaesthetic.  Strictly  speaking,  we  may  now 
say  that  this  is  a  question  less  for  the  surgeon  than 
for  the  anaesthetist,  who  is  now,  as  he  ought  to  be,  a 
responsible  specialist,  with  theory,  technique  and  ex- 
perience of  his  own.  Yet  of  course  the  operator 
himself  is  concerned,  though  in  some  measure  his 
responsibility  is  now  shared  with  the  anaesthetist. 
As  regards  alcohol  the  verdict  here  is  undisputed, 
and  will  so  remain  until,  perhaps,  Prof.  Karl  Pear- 
son takes  up  the  subject  on  the  lines  of  his  celebrated 
Memoir  on  Alcoholism  and  Offspring,  in  which  he 
forgot  to  observe  whether  the  alcohol  or  the  off- 
spring came  first  in  the  cases  under  his  study.  If 
we  avoid  this  most  fundamental  of  all  fallacies,  and 
observe  the  influence  of  alcoholism  upon  anaesthesia, 
in  cases  where  the  alcoholism  comes  first  and  the 
anaesthesia  second,  we  find  that  the  patient  is  on  the 
average  gravely  disadvantaged  in  almost  every  de- 
tail of  the  administration.  The  alcoholic  subject 
takes  the  anaesthetic  in  its  earliest  stages  very  badly, 
commonly  with  much  violence  and  delay,  wasting 
his  strength  and  requiring,  in  the  upshot,  a  larger 
dose  of  the  anaesthetic,  which  is  of  course  a  poison, 
and  of  which  the  less  he  needs  the  better  for  him. 
When  he  is  "  under/'  the  alcoholic  subject  gives  un- 


28o  SURGERY  AND  SOCIETY 

due  anxiety  to  the  anaesthetist  from  beginning  to  end. 
It  is  far  more  difficult  to  maintain  him  continuously 
at  that  particular  level  of  anaesthesia  which  is  both 
safe  and  effective.  At  one  moment  he  stops  or 
threatens  to  stop  breathing,  and  almost  at  the  next 
he  is  semi-conscious.  These  facts  are  known  to  every 
anaesthetist  and  every  surgeon.  I  have  no  first- 
hand knowledge  of  the  influence  of  modern  methods 
in  overcoming  the  initial  difficulty.  It  may  be  that 
getting  the  alcoholic  patient  "  under "  is  a  simple 
and  safe  proceeding  nowadays,  when  the  anaesthetic 
is  given  after  the  fashion  described  in  the  last  chap- 
ter. But  in  Edinburgh  ten  years  ago,  when  chloro- 
form was  given  by  the  open  method  to  patients  re- 
cruited from  classes  whose  habits  are  what  they  are 
in  Scotland,  one  saw,  almost  daily,  scenes  which  will 
not  readily  be  forgotten  as  part  of  that  indictment 
against  alcohol  to  which  every  year  lends  additional 
force  in  mind. 

If,  however,  we  consider  the  chemistry  of  alcohol, 
and  recall  its  close  alliance  with  other  anaesthetics, 
such  as  ether  (one  being  the  hydrate  and  the  other 
the  oxide  of  the  same  base,  and  their  names  being 
ethyl  alcohol  and  ethyl  ether  respectively),  we  shall 
understand  how  the  problem  of  administering  an 
anaesthetic  must  be  complicated  in  persons  who  ha- 
bitually subject  their  nervous  system  to  the  action  of 
a  very  similar  substance.  Alcohol,  ether  and  chloro- 
form all  have  the  same  solvent  action  upon  the 
lipoids  of  the  body,  this  being  the  key  to  their  neu- 
rotic and  anaesthetic  properties.  Further,  the  cen- 
tral problem  in  anaesthesia  is  the  maintenance  of  the 


SURGERY  AND  ALCOHOL  281 

respiration.  The  pulse  must  be  continuously  felt  or 
watched,  but  the  breathing  always  tends  to  stop  first, 
and  only  when  it  fails,  but  most  urgently  then,  is 
danger  at  hand.  But  the  breathing  depends  upon 
the  activity  of  the  breathing  centre,  or  "  punctum 
vitale,"  in  the  bulbar  portion  of  the  brain;  and  the 
reason  why  the  breathing  of  the  alcoholic  patient  is 
commonly  so  unsatisfactory  is  that  the  cells  of  his 
nervous  centres  have  been  injured  by  their  chronic 
intoxication.  Death  due  to  acute  alcoholism  or 
u  drunkenness  "  or  "  intoxication  "  in  the  ordinary 
sense  of  the  word  is  due  when  it  occurs  to  alcoholic 
paralysis  of  the  respiratory  centre:  the  same  cause 
as  that  of  death  from  chloroform  or  ether  or  mor- 
phia. Indeed,  this  in  the  general  rule  with  the  nar- 
cotic poisons. 

The  practical  moral  for  the  individual  reader  is 
that,  if  ever  he  proposes  to  undergo  a  surgical  opera- 
tion, he  would  do  well  to  prepare  for  the  anaesthetic 
now  by  abstinence  from  alcohol.  There  are  some 
hundreds  of  other  reasons  for  the  same  proceedings, 
but  they  are  not  relevant  here. 

But  assuming  that  the  operation  has  been  per- 
formed, and  that  the  patient,  alcoholic  or  not,  has 
survived  the  administration  of  the  anaesthetic  —  as 
all  patients  but  perhaps  one  in  nine  or  ten  thousand 
may  be  expected  to  do  nowadays,  the  chronic  alco- 
holic class  apart  —  we  now  have  to  consider  the  ad- 
visability of  using  alcohol  to  aid  him  in  the  process 
of  repair,  or  in  his  fight  against  microbes,  or  in  relief 
of  any  surgical  shock  from  which  he  may  be  suffer- 
ing.    The  consideration  of  these  questions  may  be 


282  SURGERY  AND  SOCIETY 

prefaced  by  recent  quotations  from  three  of  the  most 
distinguished  of  living  surgeons  —  Professor  Theo- 
dor  Kocher  of  Berne,  whose  instruments  and  origi- 
nal operative  procedures  are  employed  by  surgeons 
everywhere,  Sir  Victor  Horsley,  who  is  perhaps 
Kocher's  nearest  rival  amongst  living  surgeons,  after 
the  father  of  them  all,  and  Sir  Alfred  Pearce  Gould, 
now  Senior  Surgeon  to  the  Middlesex  Hospital. 
These  names  are  much  more  than  authoritative  in 
the  ordinary  sense,  and  they  are  specially  chosen 
from  amongst  any  available  number,  because  they 
abundantly  suffice  between  them  to  prove  my  point 
as  to  the  best  contemporary  surgical  practice.  I  do 
not  quote  Sir  Frederick  Treves,  since  he  has  retired 
from  practice. 

Spoken  at  the  Medical  Temperance  Breakfast, 
July  28,  1 9 10,  at  the  Imperial  Institute  in  London, 
Professor  Kocher's  words  were  as  follows: 

11  You  will  be  astonished  to  hear  that  I  am  a 
great  friend  of  alcohol,  though  I  know  from  ex- 
perience that  when  I  have  to  do  much  work,  and 
good  work,  I  must  not  drink  alcohol  at  all. 
.  .  .  So  I  am  aware,  and  appreciate  to  the 
highest  degree  all  that  temperance  societies  have 
done  for  the  welfare  of  humanity.  But  let  me 
hurry  to  say  that  I  differ  very  strongly  in  regard 
to  what  they  are  fighting  against  in  the  method 
of  the  application  of  alcohol.  We  use  alcohol 
outside  the  body  —  to  wash  our  hands,  to  disin- 
fect us,  to  make  us  clean  in  every  way  —  but 
we  are  afraid  to  introduce  it  into  the  body,  and 


SURGERY  AND  ALCOHOL  283 

I  only  wish  that  your  fighting  against  the  people 
who  use  alcohol  in  the  other  way  may  have  the 
greatest  success  to  make  them  understand  that 
the   only  rational  use   of  alcohol  is   outside   the 

body." 

Sir  A.  Pearce  Gould  spoke  as  follows  on  the  same 
occasion : 

"  For  thirty  years  and  more  I  have  practically 
growingly  abjured  the  use  of  alcohol  in  my  prac- 
tice. I  began  by  trying  to  note  what  was  the 
influence  of  alcohol  in  what  we  used  to  call  in 
earlier  days  septic  cases  —  erysipelas,  pyaemia, 
etc.,  which,  as  you  know,  were  always  treated  with 
liberal  doses.  I  commenced  by  abruptly  leaving 
off  those  liberal  doses,  and  I  remember  when  I 
knocked  off  brandy  from  a  case  of  erysipelas  the 
other  hospital  authorities  began  to  have  grave 
doubts  about  my  sanity;  but  the  patient  got  well. 
For  many  years  since  then  I  have  never  given  a 
drop  of  alcohol  to  any  case  of  so-called  septic  in- 
fection, and  anyone  looking  squarely  on  the  pro- 
toplasmic effects  of  alcohol  would  not  resort  to  its 
use  in  such  case.  And  gradually  case  after  case, 
disease  after  disease,  has  fallen  away,  so  far  as  I 
have  had  anything  to  do  with  it,  from  the  adminis- 
tration of  alcohol." 

Lastly,  from  "  Alcohol  and  the  Human  Body " 
(Fourth  Edition,  191 1),  by  Sir  Victor  Horsley  and 
Dr.  Mary  Sturge,  may  be  quoted  the  following, 
under  the  heading,  "  Disuse  of  Alcohol  in  Surgery  " : 


a84  SURGERY  AND  SOCIETY 

"The  only  surgical  condition  in  which  alcohol 
is  still  thought  by  some  to  be  of  use  is  '  shock/  and 
even  in  this  respect  it  is  now  giving  place  to  other 
and  more  scientifically  administered  measures. 
Some  of  the  present-day  rapid  recoveries  are  also 
due  to  the  fact  that  after  operation  the  patients 
are  no  longer  dosed  with  alcohol  under  the  mis- 
taken idea  that  it  hastens  recovery,  and  possibly 
also  to  the  fact  that  they  are  increasingly  encour- 
aged to  abstain  from  alcohol  before  the  surgeon 
operates.  Consequently,  apart  from  the  greater 
question  of  antiseptic  improvements,  the  processes 
of  repair  and  of  healing  proceed  more  quickly 
than  in  former  times.  The  change  is  of  course 
obvious,  in  both  the  medical  and  surgical  aspect 
of  treatment."      (p.  6). 

And  also,   under  the  heading,   "  The  Healing  of 
Wounds  delayed  by  Alcohol  " ; 

"  In  the  case  of  accidents  or  operations  all  sur- 
geons know  only  too  well  the  advantages  of  hav- 
ing to  deal  with  patients  who  are  habitual  ab- 
stainers, on  account  of  the  better  healing  of  their 
wounds.  The  reason  is  obvious:  the  protoplasm 
of  their  tissues  is  not  degenerated,  and  it  has  a 
capacity  for  growth  whereby  the  desired  union  of 
the  edges  of  the  wound  is  effected. 

"  Further,  Kreparsky  has  shown  that  alcohol- 
ism, acute  or  chronic,  lessens  the  number  of  white 
cells,  and  that  the  repair  of  wounds  takes  place 
more  slowly  in  drinkers,  because  of  the  insufficient 


SURGERY  AND  ALCOHOL  285 

supply  of  white  blood-corpuscles  at  the  area  under- 
going healing. 

"  Numbers  of  patients  accustomed  to  taking  al- 
cohol are  indeed  obliged  to  make  a  protracted  stay 
in  hospitals  on  account  of  the  slow  healing  of 
wounds  which,  had  their  tissues  been  in  a  normal 
condition,  would  have  united  rapidly.  Many 
others  are  warned  by  surgeons  that  their  healing 
power  is  likely  to  be  bad  unless  they  abstain  from 
alcohol  for  some  weeks  or  months  before  opera- 
tion.,, 

The  reader  may  well  be  content  with  the  forego- 
ing opinions  as  to  the  matter  of  fact.  But  there 
remains  the  remarkably  instructive  series  of  studies 
which  have  given  us  the  key  to  the  interpretation 
of  the  facts.  The  diminution  of  the  white  blood- 
corpuscles,  already  referred  to,  is  only  part,  though 
doubtless  an  important  part,  of  this  interpretation. 

Here  we  turn  for  guidance  to  the  world-famous 
work  of  Metchnikoff,  who  made  the  pioneer  re- 
searches, and  who,  with  his  pupils  and  followers, 
has  settled  the  question  from  the  experimental  side 
no  less  surely  than  the  surgeons  from  the  observa- 
tional and  clinical  side.  Metchnikoff,  as  the  discov- 
erer of  the  function  of  the  white  blood-corpuscles  or 
phagocytes,  was  evidently  bound  to  cultivate  the  mag- 
nificent field  of  inquiry  which  this  discovery  opened 
to  him,  by  studying  the  influence  of  all  manner  of 
agents  upon  the  behaviour  of  leucocytes  or  phago- 
cytes: and  the  most  carefully  studied  of  these  agents 
has  been  the  most  important,  which  is,  of  course, 


286  SURGERY  AND  SOCIETY 

alcohol.  The  following  was  Metchnikoff's  verdict 
so  far  back  as  1906:  "Besides  its  deleterious  in- 
fluence on  the  nervous  system  and  other  important 
parts  of  our  body,  alcohol  has  a  harmful  action  on 
the  white  blood-cells,  the  agents  of  natural  defence 
against  infective  microbes.,'  So  far  as  the  observed 
action  of  alcohol  upon  the  activity  of  leucocytes  is 
concerned,  we  cannot  do  better  than  refer  once  again 
to  Horsley  and  Sturge's  admirable  work.  They 
say:  — 

"  It  is  now  proved  that  alcohol,  even  in  tiny 
doses,  paralyses  more  or  less  the  white  cells,  which 
thus  cease  from  exercising  their  microbe-destroy- 
ing function.  Speaking  in  popular  language,  al- 
cohol renders  the  white  blood-cells  less  alert,  so 
that  they  remain  passive  and  motionless  in  the 
presence  of  dangerous  microbes,  which  it  is  their 
duty  to  promptly  destroy.  Two  Belgian  ob- 
servers, Massart  and  Bordet,  in  carrying  out  ex- 
periments on  the  attraction  and  repulsion  of  the 
living  leucocytes  by  various  bodies,  found  that 
alcohol,  even  in  very  dilute  solution,  strongly  re- 
pelled leucocytes.  Consequently,  if  alcohol  even 
in  very  minute  quantities  is  circulating  in  the 
blood,  the  leucocytes  will  not  be  able  to  make  their 
way  quickly  into  the  blood,  from  the  places  of 
their  manufacture,  and  thus  be  carried  rapidly  to 
any  place  where  they  are  urgently  needed.  In  con- 
sequence of  this  delay  a  severe  illness  frequently 
ensues:  indeed,  in  the  case  of  some  microbes,  these 
obtain  such  a  strong  foothold  that  the  leucocytes 


SURGERY  AND  ALCOHOL  287 

never  are  able  to  drive  them  out.  As  Abbott 
has  shown,  this  is  particularly  true  of  the  microbe 
that  causes  erysipelas  and  cellulitis.  The  prone- 
ness  of  brewers  and  their  draymen  to  suffer  from 
these  diseases  is  well  known. 

"  The  seriousness  of  this  adverse  influence  of 
alcohol  upon  the  vigour  and  energy  of  the  white 
blood-corpuscles  cannot  be  over-estimated. 
Herein  lies  the  explanation  of  many  infections, 
many  prolonged  illnesses,  much  chronic  ill-health, 
and  many  premature  deaths." 

To  all  this  there  is  the  evident  reply  that  the 
behaviour  of  leucocytes  in  the  presence  of  alcohol 
proves  nothing  for  the  actual  case  of  disease,  and  is 
only  relevant  on  an  assumption  —  that  the  move- 
ment of  leucocytes  is  protective  against  disease.  It 
is  necessary,  therefore,  to  put  the  matter  to  the  test, 
and  this  has  now  been  done  by  many  observers,  and 
for  many  infections,  surgical  and  medical,  to  accept 
an  obsolescent  classification.  The  final  proofs  are 
independent  of  Metchnikoff's  theory  in  its  original 
form.  That  theory  assumed  that  the  leucocytes  do 
all  the  work  that  they  appear  to  do.  But  it  is  highly 
probable  that  other  agents  aid  the  leucocytes,  if 
indeed  the  leucocytes  can  do  anything  without  them. 
It  may  be  that  the  failure  or  success,  the  inertia  or 
activity,  of  the  leucocytes  depend  essentially  upon 
changes  in  the  fluid  composition  of  the  blood;  and 
if  this  be  so  we  must  study  the  relation  of  alcohol  to 
the  processes  as  they  occur  within  the  body.  On  this 
point,  Horsley  and  Sturge  write  as  follows :  — 


a88  SURGERY  AND  SOCIETY 

"TKe  liquid  portion  of  the  living  blood,  the 
plasma,  also  has  very  definite  powers  in  assisting 
to  defend  the  body  against  invasion  by  disease 
and  microbes,  which  when  absorbed  from  the  lungs 
or  bowels  into  the  circulation,  find  their  injurious 
effect  counteracted  and  themselves  destroyed  by 
the  plasma  if  this  is  in  a  normal  healthy  state. 

"  Laitinen  has  investigated  this  question  and 
found  that  the  fluid  constituents  of  human  blood 
have,  in  the  case  of  moderate  drinkers,  a  lessened 
bactericidal  (slaying  of  bacteria)  power,  as  esti- 
mated haemolytically. 

"A  special  interest  attaches  to  this  elaborate 
and  prolonged  research,  in  that  the  microbe  em- 
ployed as  the  test  was  that  causing  typhoid  fever. 
The  test  was  applied  to  large  numbers  of  per- 
sons, in  order  to  obtain  reliable  averages.  It 
was  found  that  when  small  amounts  of  human 
blood  were  brought  in  contact  with  these  mi- 
crobes, and  the  resisting  and  conquering  power  of 
each  specimen  of  blood  estimated  separately,  the 
blood  from  those  human  beings  who  were  abstain- 
ers possessed  a  greater  power  of  resisting  the 
growth  and  development  of  the  bacteria. 

"  These  results  confirm  those  that  had  already 
been  established  by  Laitinen  as  occurring  in  ani- 
mals. The  substances  which  should  exist  in  the 
blood  to  complete  the  reaction  by  which  resistance 
is  thus  obtained  are  called  *  complements.'  " 

Dr.  Sims  Woodhead,  a  leader  among  those  who 
are  doing  the  pioneer  work  in  this  subject,  and  Pro- 


SURGERY  AND  ALCOHOL  289 

fessor  of  Pathology  in  the  University  of  Cambridge, 
says  on  this  point  that: 

"  Abbot  and  Bergery  were  the  first  to  find  that 
in  alcoholic  poisoning  these  complements  are  ir- 
regular but  distinctly  reduced,  and  they  maintain 
that  this  reduction  accounts,  first  of  all,  for  the 
impaired  power  of  nutrition  met  with  in  alcohol- 
ised  animals,  on  the  ground  that  there  are  not 
sufficient  complements  to  combine  with  the  neces- 
sary nutrient  proteid  or  albuminoid  substance  cir- 
culating in  the  blood.  Moreover,  the  lack  of 
these  complements  is  of  importance,  from  the  fact 
that  without  them  it  appears  to  be  impossible  for 
any  immunity  to  disease  to  be  set  up  in  an  animal. 
They  offer  this  as  an  explanation  of  the  fact  that 
in  alcoholism  impaired  nutrition  is  first  observed; 
and  that  this  is  accompanied  or  followed  by  an 
interference  with  the  production  of  immunity." 

Professor  Laitinen's  verdict  in  1909  ran  thus: 
"  It  seems  clear,  therefore,  that  alcohol,  even  in  com- 
paratively small  doses,  exercises  a  prejudicial  effect 
on  the  protective  mechanism  of  the  human  body  " : 
and  Professor  Welch,  a  leader  amongst  American 
pathologists,  adds  that  "  This  lowered  resistance  is 
manifested  both  by  increased  liability  to  contract  the 
disease  and  by  the  greater  severity  of  the  disease.'' 

Observations  have  been  made  with  the  microbes 
of  all  the  most  important  medical  and  surgical  in- 
fections, including  tuberculosis,  syphilis,  cholera, 
typhoid  fever,  pneumonia,  hydrophobia,  tetanus  and 


290  SURGERY  AND  SOCIETY 

anthrax.  The  action  of  alcohol  is  uniformly  dele- 
terious in  these  and  all  other  cases  in  which  the 
investigation  has  been  made.  There  is  not  one  of 
all  these  inquiries  which  has  resulted  in  favour  of 
alcohol  as  regards  any  pathogenic  microbe. 

Tuberculosis  is  the  most  deadly  of  all  diseases, 
and  in  its  surgical  forms,  which  are  numberless, 
comes  constantly  under  the  care  of  the  surgeon. 
These  cases  often  run  for  many  years,  and  every 
factor  which  weighs  against  the  patient's  powers  of 
resistance  thus  becomes  of  high  practical  importance. 
The  surgeon  cannot  hope  to  remove  all  the  tubercle 
bacilli  in  any  but  rare  cases.  The  knife  can  only  aid 
the  patient  mechanically  in  the  task  which  must  be 
performed  by  his  tissues  or  not  at  all.  In  many  of 
these  cases  now  the  surgeon  hopes  to  effect  a  cure  by 
non-surgical  means:  thus  tuberculous  glands  in  the 
neck,  and  tubercle  in  joints  and  bones,  may  undergo 
slow  cure  if  the  patient's  tissues  are  equal  to  the  task. 
But  whether  or  not  the  knife  be  employed,  it  is  these 
tissues  upon  which  all  depends. 

Comparative  statistical  inquiry  in  France  and  else- 
where has  shown  that  the  districts  in  which  most 
alcohol  is  consumed  are  those  in  which  there  is  the 
highest  incidence  of  tuberculosis.  In  Great  Britain 
the  incidence  of  tuberculosis  upon  those  who  are 
engaged  in  the  alcoholic  trade  is  far  in  excess  of  the 
average.  Commenting  upon  this  fact,  Dr.  Arthur 
Newsholme,  our  first  authority  upon  the  disease,  and 
now  Principal  Medical  Officer  to  the  Local  Gov- 
ernment Board,  writes  as  follows:  "It  has  been 
shown  that  alcohol  lowers  the  resistance  to  infection : 


SURGERY  AND  ALCOHOL  291 

in  other  words,  it  opens  the  door  to  infection;  it  pre- 
pares the  soil  on  which  the  seed  of  infection  grows. 
This  is  well  known  to  be  true  not  only  for  consump- 
tion but  also  for  such  diseases  as  pneumonia,  typhoid 
fever,  erysipelas,  blood-poisoning,  etc.  A  great 
French  physician,  Dr.  Brouardel,  has  well  stated  the 
matter  in  the  following  words  — *  Alcoholism  is  in 
effect  the  most  powerful  factor  in  the  propagation  of 
tuberculosis.  The  most  vigorous  man  who  becomes 
alcoholic  is  without  resistance  before  it.'  " 

In  order  to  render  this  part  of  the  argument  final 
in  so  far  as  scientific  opinion  can  make  it  so,  we  may 
conclude  it  by  quotation  of  the  following  resolution, 
passed  by  the  International  Congress  on  Tubercu- 
losis, which  met  in  Paris  in  1905: 

"  That  in  view  of  the  close  connexion  between 
alcoholism  and  tuberculosis,  this  Congress  strongly 
emphasises  the  importance  of  combining  the  fight 
against  tuberculosis  with  the  struggle  against  alco- 
holism." 

Precise  experimental  proof  of  this  association  has 
been  obtained  from  the  lower  animals,  where  the 
details  and  date  of  infection  and  the  intensity  of  the 
alcoholic  poisoning  can  be  precisely  observed;  and 
it  is  one  of  the  certainly  established  facts  of  science. 
Many  decades  may  be  necessary  before  we  can  in- 
terpret the  fact  in  chemical  terms,  and  there  may 
and  will  be  abundance  of  controversy  thereupon: 
but  the  fact  itself  is  established. 

Our  duty  is  plainly  indicated  by  the  above-quoted 
resolution  of  the  International  Congress  on  Tubercu- 
losis.    The  fight  against  tuberculosis  must  be  com- 


292  SURGERY  AND  SOCIETY 

bined  with  the  fight  against  alcoholism.  The  great 
agencies  which  are  now  at  work,  endeavouring  to 
educate  public  opinion  for  the  extermination  of  con- 
sumption and  the  other  forms  of  tuberculosis,  will  do 
less  than  their  duty  so  long  as  they  decline  to  give 
to  this  question  in  their  propaganda  the  importance 
which  it  possesses  in  the  facts.  But  the  lamentable 
truth  has  to  be  placed  on  record  that  when  it  is 
sought  to  bring  these  facts,  or  the  parallel  facts  of 
parental  alcoholism,  to  the  notice  of  workers  against 
consumption  and  of  Eugenists  respectively,  they 
reply,  "  We  are  not  a  temperance  society  " —  to 
which  the  only  possible  rejoinder  is  that  they  ought 
to  be. 

To  turn  to  the  question  of  our  duty  on  a  smaller 
scale,  it  may  be  pointed  out  that,  just  as  in  the  case 
of  consumptives,  so  also  in  the  case  of  surgical  tuber- 
culosis in  all  its  forms,  where  in  every  case  the  vital 
indication  is  to  maintain  and  increase  the  resistance 
of  the  patient's  tissues,  these  patients  or  their  parents 
—  for  children  are  the  chief  victims  —  are  being 
daily  deceived  with  all  manner  of  patent  medicines, 
lung  tonics,  tonic  wines  and  so  forth,  which  are  noth- 
ing else  than  masked  alcohol,  in  strong  solution,  sold 
at  outrageous  prices.  Everywhere  a  little  inquiry 
will  discover  anxious  and  devoted  parents,  scraping 
and  toiling  to  save  the  wherewithal  to  buy  these 
abominations  for  a  child  with  hip-joint  or  spine  dis- 
ease: dosing  the  victim  continuously  with  the  one 
substance  which  science  has  most  exhaustively  proved 
to  lower  the  resistance  of  the  human  or  animal  body 
to  all  forms  of  tuberculosis.     Sir  James  Barr,  of 


SURGERY  AND  ALCOHOL  293 

Manchester,  has  recently  pointed  out  that  alcohol  is 
probably  more  fatal  when  administered  in  typhoid 
fever  than  in  pneumonia  — "  the  protracted  nature 
of  the  disease  allows  this  medicament  more  time  to 
work  mischief."  How  much  more  are  these  words 
true  of  a  chronic  disease  like  tuberculosis,  where 
"  this  medicament "  may  be  systematically  adminis- 
tered for  months  or  even  years,  if  the  patient  takes 
so  long  to  succumb  to  the  variety  of  poisons  to  which 
he  is  exposed! 

There  is  no  good  reason  why  the  ubiquity  of  the 
Press,  and  the  beauty  of  the  country,  each  of  them 
precious  and  irreplaceable  things,  should  be  made  to 
serve  the  purpose  of  those  who  advertise  these  far 
worse  than  fraudulent  preparations.  In  the  United 
States  of  America  public  opinion  has  been  to  some 
extent  aroused  by  the  courageous  efforts  of  a  popular 
weekly  journal.  In  Great  Britain  little  or  nothing 
has  yet  been  done,  though  the  aggravation  of  chronic 
disease  by  the  alcohol  which  is  their  only  active  prin- 
ciple is  the  least  of  the  evils  which  flow  from  public 
and  professional  apathy  in  this  matter. 

Though  I  write  as  one  who  has  undergone  a  medi- 
cal education  and  holds  medical  and  surgical  de- 
grees, I  do  not  practise,  and  so  far  am  I  from  having 
any  bias  against  proprietary  preparations  as  such 
that,  on  the  contrary,  I  think  it  the  duty  of  one  in 
my  independent  position  to  commend  publicly  any 
which  he  believes  to  be  of  real  value  and  free  from 
danger,  and  I  have  faced  much  criticism  in  order  to 
do  so.  At  least  the  fact  should  add  weight  to  my 
words,  far  too  light  for  the  facts  as  they  are,  when  I 


294  SURGERY  AND  SOCIETY 

protest  against  the  callous  composure  with  which 
those  who  know  the  facts  permit  these  enemies  of  the 
people  to  batten  upon  lives  and  limbs.  The  open 
trade  in  alcohol  is  as  dangerous  and  disastrous  to 
those  concerned  in  it  and  to  its  patrons  as  any  trade 
ever  yet  was ;  but  what  is  to  be  said  of  this  trade  in 
masked  alcohol,  almost  wholly  consumed  by  those 
whose  infirmity,  of  one  sort  or  another,  most  urgently 
contra-indicates  the  use  of  alcohol  in  any  form  what- 
ever? I  reiterate  here  the  demand  which  I  have 
been  making  on  many  platforms  throughout  this 
country  for  many  years  past,  that,  at  the  very  least, 
if  the  legislature  is  to  levy  a  tax  on  these  things  and 
give  them  the  apparent  sanction  of  an  official  stamp, 
it  should  insist  that  every  bottle  should  bear  a  label 
stating  its  alcoholic  content.  Any  capacity  for  in- 
dignation, other  than  party-political,  is  nowadays 
looked  upon  as  so  very  "  dowdy  "  and  "  Victorian," 
and  arguing  so  little  sense  of  humour,  that  one  re- 
quires to  curb  oneself  in  dealing  with  such  subjects 
as  this:  but  the  indignation  for  which  the  few  are 
laughed  at  to-day  will  be  as  nothing  to  the  general 
indignation  of  the  many  at  no  distant  date  when  the 
facts  are  known,  and  the  supineness  of  those  who 
might  have  dealt  with  them,  but  did  not,  is  revealed. 
There  is  no  real  and  radical  remedy  but  education, 
and  the  legislative  possibilities  which  depend  upon 
it.  That  education  is  now  being  slowly  achieved: 
not  by  our  ancient  seats  of  learning,  which  have  long 
given  up  learning,  nor  by  our  public  schools,  but  by 
the  temperance  party  and  the  ill-paid,  hard-worked 
teachers  in  the  nation's  elementary  schools,  who  are 


SURGERY  AND  ALCOHOL  295 

now  giving  lessons  about  alcohol  to  the  future  citizens 
of  the  nation.  Slowly,  also,  the  practice  of  the  rank 
and  file  of  the  medical  profession  is  altering  in  ac- 
cordance with  that  of  their  leaders :  and  the  medical 
students  of  the  present  day  are  beginning  to  be 
taught  nearly  as  much  about  alcohol  and  its  effects  as 
is  found  in  the  Board  of  Education  syllabus  for  use 
in  public  elementary  schools. 

The  use  of  this  substance  has  been  totally  aban- 
doned in  the  medical  and  surgical  practice  of  the  most 
honoured  and  most  successful  practitioners  of  the 
day.  The  latest  work  in  the  production  of  immu- 
nity against  such  diseases  as  hydrophobia  and  an- 
thrax has  proved  that  the  processes  by  which 
immunity  can  be  induced  in  men  and  animals  are  ar- 
rested by  the  simultaneous  administration  of  alcohol. 
As  the  whole  trend  of  modern  medicine  and  surgery 
is  toward  the  artificial  production  of  immunity  by 
the  use  of  vaccines,  sera,  antitoxins  and  so  forth,  we 
may  be  assured  that  alcohol,  once  examined  by 
science,  has  been  condemned  beyond  recall.  It  is 
in  the  belief  that  the  people  perish  for  lack  of  knowl- 
edge —  knowledge  which  is  already  in  the  hands  of 
the  few,  that  so  much  space  has  been  devoted  to  the 
matter  here. 

One  other  point  may  be  referred  to,  as  I  have 
never  dealt  with  it  before,  and  am  constantly  being 
asked  to  satisfy  correspondents  and  doubtful  readers 
of  previous  books.  I  have  called  alcohol  a  poison, 
as  do  all  the  text-books  of  physiology,  pharmacology, 
toxicology,  pathology  and  medical  jurisprudence  that 
have'   been   published   for  some   decades   past:   but 


296  SURGERY  AND  SOCIETY 

those  readers  who  are  not  acquainted  with  such 
works,  nor  with  the  universal  classification  of  alcohol 
with  chloroform  and  ether  as  narcotic  poisons  — 
which  are  indeed  combined  in  the  anaesthetic  mixture 
called  "  A.  C.  E." —  supposed  that  this  calling  alco- 
hol a  poison  is  a  sort  of  fanatical  freak,  which  has  no 
scientific  warrant,  and  is  palpably  denied  by  the  ex- 
perience of  every  day. 

But  the  scientific  warrant  is  unquestionable. 
Many  years  ago  Sir  Andrew  Clark  said:  "  Alcohol 
is  a  poison  —  so  is  strychnine;  so  is  arsenic;  so  is 
opium.  It  ranks  with  these  agents.  Health  is  al- 
ways in  some  way  or  other  injured  by  it."  That  was 
the  opinion  of  an  acute  clinical  observer;  but  since 
his  day  it  has  been  justified  up  to  the  hilt  by  labora- 
tory experiments.  I  will  only  quote  the  verdict  of 
the  physiologist,  Professor  Fick,  and  then  we  may 
examine  the  apparent  contradiction  between  these 
two  quotations  and  the  repeated  experience  of  the 
moderate  drinker.     He  says: 

"  It  is  a  daily  occurrence  to  find  persons  un- 
accustomed to  the  use  of  alcoholic  liquors,  after 
drinking  a  small  glass  of  wine  (3  oz.)  complain 
of  dizziness,  etc.,  indicating  a  circulatory  dis- 
turbance. During  these  few  moments  it  is  hardly 
possible  that  more  than  one-third  of  the  teaspoon- 
ful  and  a  half  of  alcohol  contained  in  the  three 
ounces  of  wine  could  be  absorbed  and  find  its  way 
into  the  blood.  The  amount  of  alcohol  in  the 
blood  is  thus  less  than  one  half-volume  in  a  thou- 
sand, as  the  total  amount  of  blood  in  the  body 


SURGERY  AND  ALCOHOL  297 

is  equal  to  about  five  quarts:  and  yet  this  almost 
inappreciable  amount  of  alcohol  in  the  blood 
causes  a  very  decided  disturbance  in  the  action  of 
the  nervous  system.  Hence,  there  is  no  reason 
for  being  in  doubt  as  to  the  justice  of  calling  this 
substance  a  poison." 

The  moderate  drinker  replies  that  in  point  of  fact 
he  habitually  feels  better  for  his  glass,  that  it  en- 
ables him  to  sit  down  to  write,  that  it  helps  his 
digestion,  that  it  secures  sleep,  and  that  he  is  defi- 
nitely the  worse  in  all  these  and  many  other  re- 
spects when  he  forgoes  the  alleged  "  poison,"  which, 
he  definitely  knows,  does  him  immediate  good  in 
these  ways. 

Be  it  observed  that  the  same  is  true  of  many  other 
substances.  Sir  Andrew  Clark  likened  alcohol  to 
opium  —  which,  indeed,  it  conspicuously  resembles 
in  action  —  and  no  one  will  question  that  opium  is 
a  poison:  but  I  have  seen  one  of  the  greatest  poets 
of  the  last  generation  killed  in  two  or  three  days  for 
lack  of  the  opium  to  which  he  was  accustomed.  It 
was  for  him  the  incomparable  drug,  just  as  alcohol 
is  for  the  alcoholic,  or  tobacco  for  the  smoker.  No 
one  who  remembers  his  first  smoke  questions  that 
tobacco-smoke  contains  poisons;  one  does  not  need 
to  have  seen  nicotine  or  pyridine  injected  into  a  dog 
to  know  that.  Yet  the  smoker  knows  that  his  pipe 
helps  him  to  eat  and  digest,  to  sleep,  to  keep  his 
bowel  in  order,  to  play  and  to  work  —  most  notably 
to  read  and  to  write.  The  poison  that  was  is  now 
invaluable:  this  man's  poison  has  become  this  man's 


298  SURGERY  AND  SOCIETY 

meat.  If  the  obvious  facts  are  pointed  out  to  the 
opium-eater  or  morphinomaniac,  or  to  the  smoker, 
he  accepts  them  —  indeed,  he  knew  them  without 
being  told:  but  if  we  similarly  call  alcohol  a  poison 
that  is  fanaticism. 

The  truth  is  that  these  cases,  like  a  host  beside, 
illustrate  a  very  common  pathological  fact,  which 
consists  in  the  establishment  of  a  vicious  circle.  We 
talk  of  "  habit "  very  loosely.  Sometimes  we  mean 
an  inherited  instinct;  sometimes  we  mean  a  true  habit 
or  secondary  automatism,  looking  like  an  instinct, 
yet  really  not  innate  but  acquired;  and  sometimes, 
when  we  talk  of  a  drug  habit,  we  mean  what  is  not 
a  habit  at  all. 

The  case  may  be  best  illustrated  from  the  facts 
of  morphia,  which  have  been  worked  out  and  are 
finely  described  by  the  great  pharmacologist,  Pro- 
fessor Binz  of  Bonn  —  whence  came  a  greater  B  in 
days  gone  by.  Binz  shows  how  morphia  is  split  up 
in  the  body,  producing  an  oxidation  product,  called 
di-oxy-morphine,  which  causes  acute  symptoms  of 
depression  and  cardiac  failure,  only  to  be  relieved 
by  the  administration  of  the  antidote,  which  is  mor- 
phine. But  the  new  dose  produces  more  of  the  de- 
pressant —  and  so  the  vicious  circle  goes  on.  As  I 
say,  I  have  seen  a  great  genius  die  because  he  was 
deprived  of  sufficient  morphine  to  neutralise  the  di- 
oxy-morphine  which  was  killing  him. 

The  theory  here  put  forward  is  that  other  poisons 
behave  in  the  same  way.  The  body  seeks  to  destroy 
them  by  burning  them  up;  it  does  so  with  alcohol 
as  with  morphia,  and  alcohol  has  champions  who 


SURGERY  AND  ALCOHOE  299 

argue  that  it  is  therefore  a  food.  The  oxidation  is 
unfortunately  complicated  in  both  cases,  and  sec- 
ondary products  are  formed,  which  it  requires  a  fresh 
dose  of  the  original  poison  to  neutralise.  The  same 
is  true  of  nicotine,  and  indeed  there  is  any  number 
of  oxidisable  poisons  which  behave  in  the  same  way, 
though  only  one  of  them  finds  friends  hardy  enough 
to  call  it  a  food  on  that  account.  The  symptoms  of 
the  smoker,  which  I  myself  experienced  daily  for 
thirteen  years,  and  which  have  greatly  helped  me 
to  understand  the  parallel  symptoms  of  the  drinker, 
of  which  I  have  no  experience,  and  his  very  natural 
delusion  —  are  thus  explained:  and  so  is  the  amazing 
paradox  that  a  man  who  is  dying  of  chronic  mor- 
phinism may  be  saved  by  a  dose  of  the  drug  which 
is  killing  him.  Those  who  know  the  facts  and  are 
honest  with  themselves  and  others  will  therefore 
rightly  continue  to  call  opium,  nicotine  and  alcohol 
poisons:  and  the  public  recognition  of  the  existence 
of  food-poisons,  which  the  liver  filters  from  our  most 
innocent  forms  of  diet,  and  of  aerial  poisons,  which 
can  be  obtained  from  the  air  of  an  unventilated  and 
inhabited  room,  will  gradually  involve  the  decadence 
of  the  idea  that  nothing  is  a  poison  except,  say  an 
ounce  of  prussic  acid  in  one  dose. 

This  long  chapter  must  now  close.  It  would  ob- 
viously have  been  unscientific  to  refer  to  surgery 
alone,  for  the  demarcations  between  surgery  and 
medicine,  like  those  between  physiology  and  pathol- 
ogy, are  factitious,  and  to  respect  them  is  to  cloud 
the  truth.  I  hope  enough  may  have  been  said  to 
show  why  the  best  surgeons  nowadays  use  no  alcohol 


3oo  SURGERY  AND  SOCIETY 

at  all:  science  having  definitely  proved  that  the  bal- 
ance of  the  action  of  this  substance  upon  the  living 
body  in  health  or  disease  is  always  mortal. 

What  is  true  of  the  modern  surgeon  is  no  less  true 
of  the  modern  obstetrician,  for  this  poison  is  the 
chief  of  those  to  which  I  have  given  the  name  of 
racial  poisons.  Its  employment  in  pregnancy  injures 
the  coming  child.  Its  use  in  childbirth  lowers  ma- 
ternal resistance  to  microbes,  increases  haemorrhage, 
and  favours  the  child's  risk  of  suffocation,  owing  to 
its  action  upon  the  respiratory  centre.  In  this  life- 
giving  act  alcohol  is  the  ally  of  Death  to  all  con- 
cerned, for  exactly  the  same  reasons  as  those  which 
condemn  it  in  relation  to  the  use  of  anaesthetics  and 
the  performance  of  an  ordinary  operation.  The 
reader  who  has  seen  what  I  have  seen,  in  that  por- 
tion of  hell  called  the  Canongate  of  Edinburgh,  of 
the  influence  of  alcohol  upon  the  Surgeon  Nature's 
great  operation,  will  ask  at  the  end  of  this  chapter, 
"  How  can  anyone  write  so  feebly  and  lukewarmly 
about  this  most  mortal  abomination  of  our  time  ?  M 


CHAPTER  XIII 

MISS  FLORENCE  NIGHTINGALE 

It  is  a  commonplace  of  sociology  that  even  the 
most  individual  work  of  art  is  a  social  product. 
Similarly,  it  is  true  of  the  history  of  science  that 
great  achievements  are  built  by  many  hands  even 
though  individuality  be  as  necessary  here  as  else- 
where; and  if  we  review  the  causes  which  have 
created  modern  surgery,  we  find  that  one  of  the 
most  remarkable  women  in  history,  and  certainly  one 
of  the  most  valuable,  played  an  indispensable  part 
in  its  creation. 

We  may  say  generally  that  whatever  wounds  are, 
there  the  principles  of  Listerism  apply.  The  wound 
may  be  made  by  a  bullet  or  sword;  it  may  be  made 
by  the  surgeon's  knife;  it  may  be  visible,  as  these 
commonly  are,  or  invisible,  as  are  the  wounds  of 
child-birth.  From  one  lofty  and  secure  point  of 
view  there  can  be  no  differences  greater  than  those 
represented  by  the  wounds  involved  in  taking  life, 
the  wounds  involved  in  creating  life,  and  the  wounds 
involved  in  the  endeavour  to  save  it.  But  they  are 
all  wounds;  they  must  all  heal  if  the  patient  is  to 
live ;  and  the  laws  of  their  healing  are  the  same  in  all 
cases. 

Now  the  healing  of  wounds  is  a  more  or  less  pro- 
longed business.     Time  also  is  required  if  the  skin  is 

301 


3o2  SURGERY  AND  SOCIETY 

to  be  prepared  for  the  making  of  a  wound  under 
ideal  surgical  conditions.  Preparations  for  opera- 
tions, or  for  child-birth,  which  is  Nature's  great  oper- 
ation, and  the  after  treatment  of  this  and  man's 
operations,  require  that  the  surgeon  and  the  ob- 
stetrician shall  be  aided  by  the  nurse.  How  essential 
and  valuable  are  the  services  of  the  nurse  we  shall 
see  in  due  course,  but  as  it  is  an  object  of  this  book 
to  state  in  the  barest  outline  the  history  of  present 
achievement,  we  must  first  survey  the  work  of  Miss 
Florence  Nightingale,  without  whom,  undoubtedly, 
modern  surgery  would  not  be  what  it  is. 

So  soon  as  we  recognise  in  her  the  creator  of 
modern  nursing,  and  so  soon  as  we  realise  what 
modern  nursing  means  for  modern  surgery,  so  soon 
must  we  perceive  that  her  name  deserves  correlative 
honour  with  that  of  the  great  man  who  begat  mod- 
ern surgery.  This  is  indeed  a  product  of  the  two 
sexes,  as  all  human  products,  rightly  considered,  are ; 
since  all  human  producers  are.  The  achievement, 
as  we  now  see,  may  be  said  to  be  the  immediate 
product  of  Lister  and  Nightingale,  and  even  those 
who  have  the  folly  to  pronounce  themselves  par- 
tisans of  either  sex  will  do  well  to  forbear  if  they  are 
attempted  to  allot  a  higher  degree  of  merit  to  either 
the  indispensable  man  or  the  indispensable  woman 
whom  we  here  celebrate. 

All  our  ideas  of  merit  and  credit  are  at  the  mercy, 
if  we  knew  it,  of  the  principle  of  causation.  In 
judging  our  fellows  we  have  to  refer  to  their  physi- 
cal parents,  whom  they  did  not  choose,  and  to  their 
spiritual  parents  whom,  in  a  sense,  they  may  have 


MISS  FLORENCE  NIGHTINGALE         303 

chosen,  but  for  whom  they  are  not  responsible.  We 
have  seen  that  Lord  Lister's  spiritual  parent  was 
Pasteur,  and  it  is  interesting  to  learn  that  Miss 
Nightingale  also  had  hers.  As  Lord  Lister's  was 
a  man  so  hers  was  a  woman,  and  her  name  was 
Elizabeth  Fry.  Both  Pasteur  and  Mrs.  Fry  had 
spiritual  ancestors,  the  great  chemists  and  biologists 
on  one  side,  apostles  of   religion   and   philanthropy 

—  above  all,  George  Fox  —  on  the  other  side. 
Thus,  beginning  in  that  generation  we  may  not  un- 
fairly state  the  genealogy  of  modern  surgery  —  in- 
cluding modern  nursing,  for  the  two  are  really  one 

—  as  follows :  — 

Louis  Pasteur  Elizabeth  Fry 

1  1 

Joseph  Lister  Florence  Nightingale 

1  1 

Modern  Surgery. 

This  genealogy  may  be  criticised  by  many,  but 
perhaps  it  will  be  remembered  by  many  more,  and 
even  the  critics  may  possibly  begin  to  think  in  terms 
of  it  before  they  are  quite  aware.  Two  points  may 
be  made  before  we  pass  from  it.  The  first  is  that  on 
both  sides  we  find  ourselves  referred  to  the  Society 
of  Friends  or  Quakers,  which  gave  us  the  physical 
and  in  large  measure  the  spiritual  ancestry  of  Joseph 
Lister  himself  and,  on  the  other  side,  produced  Eliza- 
beth Fry.  The  second  point  worth  noting  is  that 
surgery  means  hand-work  and  that  the  only  reason 
why  nursing,  which  so  largely  consists  of  hand-work, 


3o4  SURGERY  AND  SOCIETY 

may  not  be  included  under  the  category  of  surgery, 
is  that  the  word  is  really  so  much  richer  and  more 
beautiful,  containing  the  idea  of  nourishment  and 
tending.  So  far  as  the  words  are  concerned,  the 
surgeon  merely  manipulates,  the  nurse  sustains. 
This  merely  by  way  of  comment  for  any  who  may 
suppose  that  the  position  and  dignity  of  surgery  are 
compromised  in  a  chapter  which  endeavours  rightly 
to  appreciate  the  woman's  contribution  to  this  great 
achievement. 

Let  us  turn  now  to  the  circumstances  of  her 
life. 

Elizabeth  Fry,  who  was  born  in  1780,  seems  very 
remote  from  the  present  day;  yet  after  all  she  was 
born  only  forty  years  before  Florence  Nightingale, 
who  died  in  19 10.  Mrs.  Fry  died  in  1845,  when 
Florence  Nightingale  was  twenty-five,  and  it  seems 
clear  that  the  great  pioneer  of  prison  reform  was 
the  directive  or  motor  influence  which,  working  upon 
Miss  Nightingale's  unique  natural  endowment,  de- 
termined the  after-history  of  her  life.  That  after- 
history  may  briefly  be  summarised  here.  The 
young  girl  was  a  granddaughter  of  William  Smith, 
the  friend  and  supporter  of  Wilberforce;  and  thus 
we  see  a  second  humanitarian  and  philanthropic  in- 
fluence, of  the  kind  much  despised  by  "  practical 
men,"  which  produced  salvation  in  the  Crimea  when 
the  "  practical  men "  were  landed  in  the  impasse 
which  awaits  all  such.  Always  the  moral  influences 
become  the  most  practical;  always  the  faddist  wins, 
always  the  crank  makes  history  —  the  right  faddist 
and  the  right  crank,  no  doubt.     But  so  far  as  the 


MISS  FLORENCE  NIGHTINGALE         305 

march"  of  mankind  is  concerned  your  "  practical 
man  "  is  but  the  beast  of  burden,  from  first  to  last. 

In  her  earliest  womanhood  Florence  Nightingale 
visited  the  chief  hospitals  in  Great  Britain  and  on 
the  Continent.  We  who  write  and  read  are  incapa- 
ble of  realising  what  kind  of  things  she  saw. 
Heaven  forfend  that  we  should  deny  to  our  prede- 
cessors, three-quarters  of  a  century  ago,  the  posses- 
sion of  all  the  qualities  of  intention  and  assiduity 
which  it  is  to  be  hoped  we  exemplify  to-day;  only 
they  lacked  knowledge.  It  is  difference  in  knowl- 
edge upon  which  essentially  depends  the  difference 
between  one  generation  and  another.  There  is  no 
reason  to  suppose  that  the  kind-hearted  and  the 
nurses  and  the  doctors  of  to-day  differ  naturally  in 
any  marked  degree  or  direction  from  countless 
hosts  of  their  predecessors.  Merely  these  know 
what  those  did  not.  This  is  the  lesson  for  the  ene- 
mies of  science;  for  the  enemies  of  research,  who 
spend  their  lives  to-day  in  making  it  more  difficult 
for  the  year  2000  to  surpass  our  own  as  it  surpasses 
the  forties  of  the  nineteenth  century. 

At  any  rate,  Miss  Nightingale  saw  what  there 
was  to  see;  which  is  not  so  easy  as  it  sounds.  She 
undertook  in  1850  the  care  of  a  Home  for  Sick 
Governesses,  and  devoted  herself  also  to  the  inter- 
ests of  ragged  schools  and  similar  institutions  for 
which  Elizabeth  Fry  had  done  so  much.  Then 
there  came  the  Crimean  War  and  the  appalling  ac- 
counts published  in  the  columns  of  the  Times  by  the 
late  Dr.  (afterwards  Sir  William  Howard)  Rus- 
sell, who  "  showed  how  the  commonest  accessories 


3o6  SURGERY  AND  SOCIETY 

of  a  hospital  were  wanting;  how  the  sick  appeared 
to  be  tended  by  the  sick,  and  the  dying  by  the  dying; 
how,  indeed,  the  manner  in  which  the  sick  and 
wounded  were  being  treated  was  worthy  only  of  the 
savages  of  Dahomey;  and  how,  while  our  own  med- 
ical system  was  shamefully  bad,  that  of  the  French 
was  exceedingly  good,  and  was,  too,  rendered  still 
more  efficient  because  of  the  Sisters  of  Charity,  who 
had  followed  the  French  troops  in  incredible  num- 
bers." 1 

This  passage  is  of  special  interest  because  it  serves 
as  an  index  in  some  manner  of  what  Lord  Lister  and 
Miss  Nightingale  have  achieved.  The  Sister  of 
Charity  as  we  find  her  at  the  present  day  on  the 
Continent  of  Europe  doubtless  has  all  the  qualities 
which  she  had  half  a  century  ago.  She  usually  has 
many  personal  qualities  which  are  not  to  be  found  in 
every  modern  nurse.  But  so  far  as  knowledge  is 
concerned,  she  remains  where  she  was,  or  almost 
where  she  was,  at  that  time  —  which,  so  far  as  sur- 
gery and  nursing  are  concerned,  is  antiquity,  Ho- 
meric in  its  remoteness  from  the  knowledge,  the 
practice,  and  the  achievements  of  to-day.  "  Effi- 
cient "  is  the  last  word  that  could  be  applied  to  the 
Sister  of  Charity  from  the  physical  and  bacteriolog- 
ical standpoint  to-day.  The  perfect  nurse  of  the  fu- 
ture will  combine  her  psychological  efficiency,  as  we 
may  call  it,  with  the  scientific  knowledge  and  prac- 
tice  of  the   modern  nurse.     It   is   hoped   that   the 

1  This  passage  is  quoted  from  the  Times  Obituary  Notice  of 
Miss  Nightingale,  August  15,  1910,  to  which  I  am  also  indebted 
elsewhere  in  the  course  of  this  chapter. 


MISS  FLORENCE  NIGHTINGALE         307 

reader  will  pardon  these  interruptions  to  our  story, 
but  this  one,  at  any  rate,  was  inevitable. 

It  was  in  October,  1854,  that  Miss  Nightingale 
wrote  to  Mr.  Sidney  (afterwards  Lord)  Herbert, 
Secretary  at  War,  offering  to  go  to  Scutari.  Her 
letter  was  crossed  by  one  to  herself  from  Mr.  Her- 
bert, who  perceived  that  "  a  number  of  sentimental 
and  enthusiastic  ladies  turned  loose  in  the  hospital 
at  Scutari  would  probably,  after  a  few  days,  be  mises 
a  la  porte,  by  those  whose  business  they  would  inter- 
rupt and  whose  authority  they  would  dispute."  As 
everyone  knows,  Miss  Nightingale  went,  and  the 
great  work  was  done;  though  this  did  not  prevent 
"  a  number  of  sentimental  and  enthusiastic  ladies  " 
from  being  justly  described  as  a  plague  of  women  by 
Sir  Frederick  Treves  in  South  Africa  half  a  century 
later.  Here  also  is  abundant  room  for  comment, 
but  at  least  let  no  one  suppose  that  in  order  to  be  a 
Florence  Nightingale  it  is  simply  necessary  to  pos- 
sess sympathy  and  pity  raised  to  their  highest  power. 
Genius,  such  as  we  celebrate  in  this  book,  is  a  com- 
plex, happily  and  with  justesse  composed  of  many 
constituents.  A  sufficiency  of  pity  will  no  more 
make  a  Florence  Nightingale  than  a  sufficiency  of 
dexterity  will  make  a  Lister. 

Florence  Nightingale  not  merely  did  her  work  in 
the  Crimea  —  work  done  despite  the  enmity  and 
criticism  of  religious  sectaries  and  of  officialism  both 
at  home  and  in  the  Crimea.  The  end  of  the  war 
was  really  the  beginning  of  that  part  of  her  work 
which  endures  and  will  endure;  for  there  is  no  dis- 
charge in  that  war.     Already,  however,  history  and 


3o8  SURGERY  AND  SOCIETY 

fame  are  taking  their  customary  course.  To  the 
public  at  large  Miss  Nightingale  is  the  "  Lady  with 
the  Lamp  ";  the  woman  who  was  brave  and  pitiful 
enough  to  go  to  the  Crimea  to  turn  the  pillow  and 
moisten  the  lips  of  the  dying.  She  is  known  by 
Longfellow's  poem  and  by  the  efforts  of  painters, 
and  is  remembered  in  connexion  with  the  Crimea. 
But  the  true  history  of  this  matter  is  very  different. 
If  the  Crimea  was,  as  John  Bright  suggested,  prop- 
erly to  be  spelt  "  a  crime,"  it  were  best  quickly  for- 
gotten or  remembered  as  an  awful  example:  save 
only  that  it  served  the  great  function  of  starting 
Miss  Nightingale  upon  the  construction  of  modern 
nursing.  In  the  ultimate  verdict  of  history,  when 
England  and  France  and  Russia  and  Turkey  are  lit- 
tle more  than  names  for  the  antiquary,  it  may  be 
that  that  war  will  have  one  title  to  general  re- 
membrance, in  that  it  was  the  dominant  circumstance 
wherein  modern  nursing  was  born. 

The  National  Fund  to  Miss  Nightingale  was  ad- 
mirably devoted,  at  her  wish,  to  the  establishment 
of  the  Florence  Nightingale  Home  for  Nurses  at 
St.  Thomas's  Hospital  and  to  the  maintenance  and 
instruction  of  Midwifery  Nurses  at  King's  College 
Hospital.  It  was  a  singular  sequence  that  from  war 
should  be  born  the  new  epoch  in  the  care  of  those 
who  create  the  life  of  this  world  to  come. 

First  of  all,  as  might  be  expected,  it  was  in  mili- 
tary nursing  that  Miss  Nightingale's  knowledge  and 
wisdom  were  first  sought.  Military  nursing  largely, 
though  by  no  means  wholly,  means  surgical  nursing, 


MISS  FLORENCE  NIGHTINGALE         309 

and  it  is  interesting  to  notice  how  close  was  the 
association  in  time  between  this  work  of  Miss  Night- 
ingale's and  the  earlier  scientific  researches  of  Lord 
Lister.  Fortunately  for  him  and  his  work,  Miss 
Nightingale,  who  was  seven  years  his  senior,  and 
the  Crimean  War  came  first.  The  work  of  the  late 
fifties  and  early  sixties  largely  achieved  those  nurs- 
ing conditions  which  were  so  necessary  for  the  suc- 
cess of  Lister's  reform,  and  which  Listerism  in  its 
turn  made  so  much  more  necessary. 

Military  nursing  was,  of  course,  completely  revo- 
lutionised by  Florence  Nightingale.  Following  up 
the  personal  services  she  had  already  rendered  in 
the  East  in  regard  to  the  Army  nursing,  she  pre- 
pared, at  the  request  of  the  War  Office,  an  exhaust- 
ive and  confidential  report  on  the  working  of  the 
Army  Medical  Department  in  the  Crimea  as  the 
precursor  to  complete  reorganisation  at  home;  she 
was  the  means  of  inspiring  more  humane  and  more 
efficient  treatment  of  the  wounded  both  in  the  Amer- 
ican Civil  War  and  the  Franco-German  War;  and 
it  was  the  stirring  record  of  her  deeds  that  led  to  the 
founding  of  the  Red  Cross  Society,  now  established 
in  every  civilised  land.  By  the  Indian  Government 
she  was  almost  ceaselessly  consulted  on  questions  af- 
fecting the  health  of  the  Indian  Army.  On  the 
outbreak  of  the  Indian  Mutiny  she  even  offered  to 
go  out  and  organise  a  nursing  staff  for  the  troops  in 
India.  The  state  of  her  health  did  not  warrant  the 
acceptance  of  this  offer;  but  no  one  can  doubt  that, 
if  campaigns  are  fought  under  more  humane  condi- 


310  SURGERY  AND  SOCIETY 

tions  to-day  as  regards  the  care  of  wounded  soldiers, 
the  result  is  very  largely  due  to  the  example  and 
also  the  counsels  of  Florence  Nightingale. 

As  we  have  already  seen,  the  nation  which  pro- 
duced this  wonderful  woman  and  also  Lord  Lister, 
may  have  learnt  its  lesson  from  her  but  certainly  has 
not  learnt  its  lesson  from  him,  so  far  as  warfare  is 
concerned.  This,  of  course,  is  not  the  fault  of  the 
surgeons;  it  is  the  fault  of  the  incurable,  boastful, 
gratified,  and  lethal  ignorance  which  fought  Miss 
Nightingale  in  the  Crimea  half  a  century  ago  and 
which  produced,  quite  lately,  a  Field-Marshal's  re- 
mark that  medical  advice  is  a  very  good  thing  — 
when  it  is  asked  for. 

The  military  aspects  of  Miss  Nightingale's  work 
are  the  popular  ones  and  the  least  important. 
Wars  play  a  great  part  in  history  books;  they  are 
not,  however,  the  essentials  but  the  incidents  of  the 
history  of  civilisation.  One  of  the  essentials  of  that 
history  is  the  creating  of  the  trained  nurse,  and  that 
was  Miss  Nightingale's  work.  She  perceived,  from 
the  first,  that,  as  she  said,  "  one  of  the  chief  uses  of 
a  hospital  (though  almost  entirely  neglected  up  to 
the  present  time)  is  this  —  to  train  nurses  for  nurs- 
ing the  sick  at  home."  We  have  seen  that  the  na- 
tion's offering  to  her  was  devoted  to  this  purpose. 
Many  years  later  Queen  Victoria's  Jubilee  Institute 
for  Nurses  followed  on  the  earlier  results  of  Miss 
Nightingale's  work,  and  to  her  also  must  be 
awarded  the  honour  of  having  substituted  the 
trained  nurse  for  utter  incompetence  in  the  care  of 
the  sick  pauper.     But  above  all,  we  must  recognise 


MISS  FLORENCE  NIGHTINGALE         311 

the  supreme  service  of  this  woman  to  the  supreme 
function  of  womanhood.  He  who  thinks  of  Lister- 
ism  only  in  its  relation  to  war  or  only  in  its  relation 
to  surgical  operations,  ignoring  what  Pasteur  and 
Lister  have  done  for  motherhood,  is  simply  commit- 
ting the  ordinary  but  fatal  error  of  placing  things 
transient  and  secondary  above  the  one  thing  essen- 
tial. We  must  avoid  this  error  when  we  study  the 
work  of  Florence  Nightingale.  It  was  in  1871  — 
just  a  year  or  two,  as  we  may  notice,  after  the  intro- 
duction of  carbolic  acid  by  Lister  —  that  Miss 
Nightingale  published  her  "  Introductory  Notes  on 
Lying-in  Hospitals."  Ten  years  later  she  referred 
to  that  little  book,  in  a  letter  written  to  the  lady 
who  was  seeking  to  found  what  is  now  the  Mid- 
wives'  Institute,  in  the  following  forcible  and  veri- 
table terms : 

"  The  main  object  of  the  Notes  was  (after  deal- 
ing with  the  sanitary  question)  to  point  out  the 
utter  absence  of  any  means  of  training  in  any  exist- 
ing institutions  in  Great  Britain.  Since  the  Notes 
were  written,  next  to  nothing  has  been  done  to 
remedy  this  defect.  .  .  .  The  prospectus  is 
most  excellent.  ...  I  wish  you  success  from 
the  bottom  of  my  heart  if,  as  I  cannot  doubt,  your 
wisdom  and  energy  work  out  a  scheme  by  which  to 
supply  the  deadly  want  of  training  among  women 
practising  midwifery  in  England.  (It  is  a  farce  and 
a  mockery  to  call  them  midwives  or  even  midwifery 
nurses,  and  no  certificate  now  given  makes  them  so.) 
France,  Germany,  and  even  Russia  would  consider 
it  woman-slaughter  to  practise  as  we  do." 


312  SURGERY  AND  SOCIETY 

Elsewhere  we  study,  as  adequately  as  may  be,  the 
facts  which  justified,  and  still  too  often  justify,  Miss 
Nightingale's  words.  There  is  plenty  of  woman- 
slaughter  to  be  recorded,  still  committed  by  doctors 
and  nurses  alike  to  whom  the  names  of  Lister  and 
Nightingale  are  nothing,  and  who  practise  in  all 
essentials  the  methods  of  barbarism.  Modern  ob- 
stetrics is  a  really  new  thing  in  the  world;  nothing 
more  beneficent,  nothing  more  fundamental  for 
the  continuance  of  mankind  can  be  named.  It  dates 
definitely  from  the  years  hitherto  celebrated  in  his- 
tory —  as  it  will  not  always  be  written  —  as  those 
of  the  Franco-Prussian  War.  While  that  was  go- 
ing on,  Lord  Lister  was  demonstrating  the  facts  our 
knowledge  of  which  enables  us  to  protect  the  woman 
in  childbirth,  and  Miss  Nightingale  was  writing  her 
14  Introductory  Notes."  The  modern  obstetrician 
and  obstetric  nurse  or  midwife  are  the  offspring  of 
these  two  parents  and  their  vital  work  in  those  mor- 
tal years. 

Before  we  pass  on  to  consider  the  nature  the 
meaning  and  the  consequences  of  the  revolution 
which  Miss  Nightingale  achieved,  let  us,  in  leaving 
her  life  and  personality,  learn  to  perceive  in  her 
the  supreme  illustration  of  a  principle  to  which  this 
present  commentator  has  often  directed  attention. 

For  me  it  is  as  clear  as  the  sun  at  noon  and  as 
continuous  as  the  ether  through  which  he  shines 
that  womanhood  always  was  and  ever  must  be  con- 
secrated first  and  last  to  motherhood.  But  it  is  also 
clear  that,  though  for  the  sub-human  female  there 
is  no  other  motherhood  than  that  which  is  physical 


MISS  FLORENCE  NIGHTINGALE         313 

and  individual  and  concrete,  for  womanhood  there 
are  further  possibilities.  Human  motherhood  may 
be  and  is  both  physical  and  psychical.  The  human 
mother  bears  and  she  tends,  and  a  woman  may  tend 
though  she  does  not  actually  bear.  The  conditions 
of  human  life  and  especially  of  human  infancy  are 
such  that  the  tending  is  as  important  as  the  actual 
bearing,  since  we  are  born  so  helpless  and  so  long 
helpless.  Thus,  though  I  hold  that  all  women  fail 
unless  they  achieve  motherhood  —  or,  if  they  suc- 
ceed, succeed  not  as  women  but  as  neuters  —  and 
though  no  modern  demonstrations  of  feminine  ca- 
pacity, in  whatever  direction,  can  dissuade  from  that 
opinion  anyone  who  studies  human  life  from  the 
standpoint  of  the  biologist,  yet  I  hold  no  less  ear- 
nestly that  women  may  succeed  and  succeed  abun- 
dantly in  achieving  a  worthy  and  happy  individual 
destiny,  altogether  apart  from  physical  motherhood, 
by  means  of  what  we  may  call  Foster-motherhood. 
Whenever  one  urges,  in  public  or  in  private,  the 
proposition  that  woman  is  made  for  motherhood, 
it  is  replied,  reasonably  enough,  that,  in  a  country 
such  as  Great  Britain,  where  there  are  one  and  a 
third  millions  of  "  superfluous  women,"  this  is  to 
condemn  a  large  proportion  of  the  sex  to  failure 
under  any  monogamous  form  of  marriage.  The 
reply  to  this  criticism  is  that  human  motherhood 
obviously  has  two  aspects,  which  may  be  called 
respectively  physical  and  psychical,  and  that  the 
purely  physical  aspect  of  motherhood,  which  was 
once  the  whole  of  it,  is  amongst  ourselves  only  a 
part,  and  in  a  sense  a  lesser  part.     Lesser  it  can 


3H  SURGERY  AND  SOCIETY 

never  be  from  the  racial  point  of  view,  since  it  is 
obviously  indispensable;  but  it  is  indeed  lesser  from 
the  individual  point  of  view.     Many  a  maiden  aunt, 
for  instance,  has  fulfilled  her  maternal  destiny,  and 
achieved  the  highest  happiness  and  worthiest  devel- 
opment   of    herself,    by    mothering    nephews    and 
nieces,    the    lack    of    merely    physical    or    organic 
motherhood  notwithstanding.     It  is,  therefore,  con- 
venient to  speak  of  motherhood  and  foster-mother- 
hood, and  to  declare,  as  one  may,  that  these  terms 
between  them  cover  the  whole   duty,   destiny,   and 
happiness    of    all    except    evidently    aberrant    and 
quasi-neuter    women.     Foster-motherhood,    as    thus 
understood,  will  include,  and  will  guide  us  to,  all 
those  functions  of  which  the  essential  character  is 
maternal,    and   therefore   womanly.     All   forms   of 
nursing,  of  course,  come  first  in  the  category:  infant 
nursing,  military  nursing,  ordinary  sick  nursing,  ob- 
stetric   nursing,    and    midwifery;    and    the    whole 
training  and  education  of  infancy  and  young  child- 
hood must  evidently  be  included.     Whenever  and 
wherever  there  is  life  to  be  tended,  nourished  or 
nursed   (the  words  are  variants  of  the  same),  edu- 
cated, and  saved,  whether  the  life  be  yet  unborn, 
or  new-born,  or  senile,  or  ill,  there  is  the  field  for 
womanhood  exercising  its  great  function  of  foster- 
motherhood.     Historically,   all  these   functions  and 
possibilities  are  to  be  traced  to  the  maternal  instinct 
and  its  correlative  tender  emotion,  aroused  by  the 
spectacle  of  helpless  infancy,  as  Dr.  McDougall  has 
clearly  shown  in  his  remarkable  work  on  "  Social 
Psychology." 


MISS  FLORENCE  NIGHTINGALE         315 

Need  it  be  said  that  the  supreme  example  of  this 
principle,  whose  name  and  fame  one  has  long  been 
in  the  habit  of  employing  to  illustrate  it,  is  Miss 
Florence  Nightingale?  The  "Lady  with  the 
Lamp  "  is  to  be  honoured  as  the  greatest  foster- 
mother  in  history.  What  a  lesson  alike  for  those 
who  see  no  role  for  unmarried  womanhood,  and  for 
those  who  seek  nowadays  to  deny  and  decry  the 
distinctive  attributes  of  womanhood  in  favour  of 
those  functions  —  humbler,  as  one  thinks  —  which, 
really  distinctive  of  neither  sex,  are  commonly  called 
masculine!  It  seems  to  be  imagined  that  Florence 
Nightingale  is  to  be  remembered  because  she  once 
did  something  for  soldiers  in  the  Crimea.  That 
was  a  great  deed;  but  it  was  merely  the  beginning 
of  her  life's  achievement.  She  is  the  greatest  fos- 
ter-mother in  history  because  she  is  the  creator  of 
modern  nursing,  and  because  her  "  Introductory 
Notes  on  Lying-in  Hospitals/'  published  in  1871, 
led  to  the  creation  of  the  modern  obstetric  nurse 
and  midwife,  who  save  the  lives  of  countless  mothers 
and  infants  throughout  the  world  every  year. 

Soldiers  and  mothers  have  only  one  friend  who 
can  be  named  beside  this  woman.  Lord  Lister, 
seven  years  Florence  Nightingale's  junior,  intro- 
duced carbolic  acid  into  surgery  in  1868.  He  and 
she,  each  in  the  manner  for  which  Nature  or  Provi- 
dence fitted  them,  were  simultaneously  inaugurating 
the  new  era  —  he  the  foster-father,  she  the  foster- 
mother  of  myriads  of  this  generation,  and  unthink- 
able millions  of  those  who  are  to  be.  His  methods 
demanded  the  trained  nurse,  both  for  surgery  and 


316  SURGERY  AND  SOCIETY 

midwifery,  both  for  the  battle-field,  where  life  is 
destroyed,  and  for  the  lying-in  room,  where  it  is 
made ;  and  her  work  was  to  provide  the  training  and 
the  principles,  the  ideals  and  the  enthusiasm,  and 
the  tiniest,  humblest  details,  too,  whereby  the  modern 
nurse  is  made.  These  two  are  scarcely  to  be 
matched  among  the  saviours  and  makers  of  life. 
Pasteur,  indeed,  is  the  spiritual  father  of  Lister  and 
many  more;  and  Elizabeth  Fry,  as  we  have  seen, 
was  the  spiritual  mother  of  Florence  Nightingale; 
but  it  is  safely  to  be  asserted  that  of  all  women 
hitherto,  apart  from  the  indirect  influence  upon  man- 
kind of  the  mothers  of  great  religious  founders, 
Florence  Nightingale  is  the  foremost  as  a  foster- 
mother  indeed.  When  the  Crimea  and  the  com- 
batants therein  are  but  names  for  the  antiquary,  her 
creative  breath  will  still  ebb  and  flow  anew  in  the 
life  of  this  world  to  come. 


CHAPTER  XIV 

THE  MODERN  NURSE 

The  modern  nurse,  at  once  a  product  and  a  condi- 
tion of  Listerism,  is  a  really  new  product  of  our 
civilisation.  She  discharges  the  oldest  and  most 
characteristic  of  womanly  functions,  but  she  does  so 
in  a  new  way.  The  difference,  of  course,  is  consti- 
tuted by  knowledge,  and  it  is  so  great  that  the  mod- 
ern nurse,  taking  an  ordinary  surgical  case,  must  be 
reckoned  far  superior  as  a  surgeon  to  Pare  or  Hun- 
ter. She  knows  and  she  practises  the  first  principles 
of  healing,  which  were  unknown  to  those  great  mas- 
ters. But  before  we  study  more  carefully  the  qual- 
ifications and  the  value  of  the  nurse  in  modern 
surgery,  we  may  observe  two  opposite  errors  into 
which  many  fall  regarding  the  conditions  under 
which  the  good  nurse  is  to  be  found. 

There  is  first  the  error  of  supposing  that  the  good 
nurse  can  be  made  at  all.  It  is  of  course  not  so, 
and  the  error  leads  and  will  lead  to  disappointment. 
The  good  nurse  of  either  sex  is  a  product  of  both 
nature  and  nurture.  He  or  she  is  born  and  made 
also.  Until  the  modern  era,  the  nature  of  the  nurse, 
we  may  say,  was  everything  and  the  nurture  almost 
nothing.  The  utmost  that  a  nurse  could  possess  was 
certain  natural  qualifications.  To-day  we  are  apt 
to   suppose,   remembering  the  technical  knowledge 

317 


318  SURGERY  AND  SOCIETY 

peculiar  to  our  time,  that  these  natural  qualifications 
are  of  no  importance  or  that  they  can  be  replaced 
by  training. 

We  must  learn,  therefore,  that  many  are  called 
but  not  all  are  chosen.  The  natural  qualifications 
for  the  making  of  the  satisfactory  nurse  are  fortu- 
nately by  no  means  uncommon.  I  will  not  wait  to 
argue  whether  they  are  more  common  in  either  sex; 
suffice  it  that  many  women  possess  them  in  consid- 
erable degree.  Sympathy,  patience,  tact,  courage, 
resolution  and  faithfulness  are  amongst  the  qualifi- 
cations demanded.  Only  the  rudest  imitations  of 
them  can  be  implanted  by  training,  and  the  nurse 
who  does  not  possess  them  will  fail  those  who  de- 
pend upon  her  no  less  certainly  than  if  she  had  not 
been  trained  at  all.  These  are  remarks  of  course 
which  apply  equally  to  the  doctor,  the  clergyman, 
or  anyone  else  whose  business  involves  intimate  and 
vital  relations  of  a  personal  kind  with  his  fellows. 
They  do  not  mean  that  training  is  less  necessary  for 
the  nurse  than  for  these,  nor  that  it  is  to  be  con- 
demned as  unsatisfactory  because  its  introduction 
fails  the  expectations  of  those  who  supposed  that 
here,  though  certainly  nowhere  else,  training  can  do 
everything. 

The  theoretical  moral  is  obvious;  it  ratifies  the 
Eugenist  who  declares  that  education,  training,  nur- 
ture are  only  secondary  in  the  making  of  human 
beings.  The  practical  moral  is  no  less  obvious.  It 
is  that  the  public  must  not  be  misled  into  suppos- 
ing that  the  possession  of  a  certificate  suffices  for 
the  nurse  it  needs  in  its  hour  of  crisis.     It  will  be 


THE  MODERN  NURSE  319 

shown  in  a  moment  that  only  the  grossest  folly  will 
seek  for  a  nurse  nowadays  who  has  not  been  genu- 
inely trained.  But,  on  the  other  hand,  if  we  are 
wise  we  shall  seek  for  evidence  in  making  our  choice 
such  as  no  certificates  can  furnish.  It  is  of  course 
the  same  with  the  choice  of  a  doctor.  Wise  people 
do  not  dream  of  consulting  a  soi-disant  doctor  who 
has  no  evidence  of  training,  but  on  the  other  hand 
they  do  not  suppose  that  the  evidence  of  training 
suffices.  They  search  for  testimony  of  another 
kind.  Now  in  choosing  a  nurse  the  public  cannot 
really  do  better  than  choose  its  doctor  rightly,  and 
then  accept  the  nurse  he  chooses.  The  right  kind 
of  doctor  will  employ  the  right  kind  of  nurse.  She 
will,  of  course,  be  trained,  but  she  will  also  be  pre- 
destined, and  the  doctor,  because  he  is  also  trained 
and  predestined,  will  have  chosen  her  accordingly. 
Once  found,  this  right  kind  of  nurse  is  amongst  the 
most  valuable  of  the  friends  of  the  family.  The 
longer  she  and  the  family  have  known  each  other 
the  more  valuable  will  she  be.  You  cannot  treat 
her  too  well  nor  value  her  too  highly. 

When  she  first  comes  to  you,  and  you  know  noth- 
ing of  her  ways  nor  she  of  yours,  you  must  remem- 
ber that  she  has  the  highest  credentials  because  the 
doctor  whom  you  trust  has  chosen  her,  and  you 
must  not  be  too  ready  to  disapprove.  Remember 
also  that  however  nice  you  may  be,  she  does  not  al- 
ways have  to  deal  with  nice  people  by  any  means. 
There  is  every  likelihood  of  her  being  imposed  upon 
and  her  value  underrated.  She  probably,  there- 
fore,  pitches   her   claims  high,    and  you  may   feel 


320  SURGERY  AND  SOCIETY 

rather  inclined  to  resent  them.  Here  is  your  op- 
portunity for  a  little  patience.  Remember  that  her 
duty  is  to  her  patient  and  to  the  doctor  for  the  pa- 
tient; not  in  the  least  to  her  patient's  friends,  even 
though  these  may  pay  her.  She  is  in  the  somewhat 
peculiar  relation,  therefore,  of  not  having  to  please 
or  satisfy  her  employers,  and  they  must  remember 
this.  Assuming  you  to  be  the  patient's  sister,  shall 
we  say,  it  does  not  in  the  least  matter  whether  you 
like  her  but  whether  the  patient  likes  her.  Fur- 
ther, the  mere  fact  that  she  has  begun  to  take  charge 
of  the  case  is  a  substantial  argument  from  the  pa- 
tient's point  of  view  against  premature  dissatisfac- 
tion with  her.  At  present  there  is  no  doubt  that  the 
nurse  is  in  a  somewhat  anomalous  position.  Her 
status  is  ill-defined.  Apart  from  her  professional 
status  she  herself  may  be  of  widely  variable  social 
antecedents,  and  the  public  has  not  yet  learnt 
whether  to  regard  her  as  an  ally,  if  not  almost  an 
equal,  of  the  doctor  —  or,  on  the  other  hand,  as  a 
domestic  servant  who  gives  herself  airs.  Now  the 
plain  truth  is  that  the  modern  nurse  belongs  to  the 
former  category  and  not  the  latter.  She  is  very 
likely  the  equal  of  her  employer  in  social  antece- 
dents; she  is  almost  certainly  the  superior  of  her 
employer  in  knowledge,  in  self-control,  and  in  her 
value  to  society.  Choose  her  well,  then  treat  her 
well,  and  in  the  hours  or  days  upon  which  all  hangs, 
she  will  not  fail  you. 

We  have  wandered  somewhat  perhaps  from  the 
discussion  of  our  first  error,  which  was  that  the 
natural  and  irreplaceable  qualifications  for  nursing 


THE  MODERN  NURSE  321 

can  safely  be  ignored  in  these  days.  Let  us  turn 
now  to  its  counterpart,  which  is  the  error  of  sup- 
posing that  training  is  superfluous.  People  are  still 
to  be  found  who  think  that  a  nurse's  duties  are 
partly  menial  and  partly  angelic  —  making  the  bed 
and  smoothing  the  midnight  pillow.  Such  people 
grudge  the  fees  which  the  modern  nurse  demands 
and  earns.  More  serious  still,  they  suppose  that 
their  opinion  is  worthy  to  rank  with  hers,  and  in  the 
absence  of  the  doctor  and  his  orders  they  may  ham- 
per the  nurse  most  seriously  in  the  performance  of 
her  duties.  Here,  then,  is  an  error  which  requires 
to  be  animadverted  upon.  Modern  nursing  re- 
quires training,  for  many  important  and  critical  du- 
ties which  are  intermediate  between  making  the 
bed,  on  the  one  hand,  and  smoothing  the  midnight 
pillow,  on  the  other  hand.  The  training  for  these 
duties  is  necessarily  long  and  expensive,  and  money 
is  never  spent  to  better  profit  than  in  paying  the 
very  moderate  fees  which  a  good  nurse  earns  many 
times  over.  The  attempt  to  save  money  by  doing 
without  a  nurse  when  the  doctor  wants  one  or  by 
employing  an  untrained  person  is  likely  to  be  dis- 
astrous. It  is  often  argued  by  devoted  friends  that 
loving  hands  ought  to  do  the  work  of  nursing  apart 
altogether  from  the  question  of  money.  They  hate 
the  idea  of  delegating  this  intimate  and  important 
work  to  an  outsider;  nor  do  they  care  to  be  treated 
as  intruders  in  the  sick-room,  nor  to  have  to  obey 
the  orders  of  one  whom  they  regard  as  an  under- 
ling. One  cannot  but  sympathise  with  such  feel- 
ings, but  they  must  be  qualified  by  completer  knowl- 


322  SURGERY  AND  SOCIETY 

edge  of  the  nurse's  functions  and  qualifications.  In 
the  light  of  that  knowledge  we  shall  realise  that 
loving  hands,  which  we  have  not  been  trained  to 
clean  on  surgical  principles,  may  work  irremediable 
harm,  where  hands  less  loving  but  trained  and  duti- 
ful will  do  nothing  but  good.  We  shall  learn  also 
that  the  nurse's  knowledge  and  training  are  such  as 
entirely  to  supersede  our  amateur  theories  and  the 
scraps  of  information,  blended  with  superstition, 
which  we  have  derived  partly  from  hearsay,  partly 
from  ancestral  practice,  partly  from  the  most  up- 
to-date  contributions  of  medical  correspondents  of 
the  daily  press.  We  commonly  do  not  realise  in  the 
least  what  a  strange  jumble  our  medical  knowledge 
consists  of  —  perhaps  a  rich  blend  of  some  medi- 
aeval delusion  about,  shall  we  say,  "  keeping  the  air 
away  from  the  wound,"  with  some  modern  theory 
of  immunity  which  is  removed  by  fifty  stages  of 
increasing  knowledge  from  that  ancient  delusion. 
Add  the  circumstance  that  our  judgment  is  vitiated 
by  a  blend  of  emotions,  sympathy  and  fear  for  the 
loved  patient,  distrust  for  the  stranger,  chagrin  at 
our  own  supersession  —  and  surely  it  will  be  seen 
that  our  views  and  proposals  are  likely  to  do  nothing 
but  harm  if  pitted  against  those  of  the  nurse.  In 
short,  we  must  learn  that  we  have  engaged  an  ex- 
pert and  must  trust  her. 

I  well  know  that  this  is  easier  said  than  done. 
The  commentator  who  is  a  doctor  himself  is  usually 
unable  to  realise  the  feelings  of  a  patient's  friends 
because  even  when  his  own  folk  are  ill  he  is  at  any 
rate  one  of  the  consultants.     But  on  one  occasion, 


THE  MODERN  NURSE  323 

at  any  rate,  the  present  writer  was  debarred  from 
visiting  a  patient  for  whom  he  had  much  concern, 
and  in  twenty-four  hours  he  had  experienced  at 
first-hand  all  those  emotions  which  we  are  now  dis- 
cussing. He  distrusted  the  doctor  whom  he  had 
himself  chosen;  he  took  a  dislike  to  the  excellent 
Nursing  Home  in  which  the  patient  lay;  at  every 
stage  he  wanted  to  intervene,  and  felt  dissatisfied 
with  all  the  news  vouchsafed  him  from  the  sick- 
room, just  as  other  people  do.  Perhaps  this  ex- 
perience may  add  to  the  value  of  what  is  now  being 
written. 

At  any  rate  let  us  convince  ourselves  that  the 
modern  nurse  is  really  an  expert,  and  that  she  is 
engaged  in  a  business  which  requires  an  expert. 
The  truth  is  that  if  one  were  to  choose  in  any  or- 
dinary case,  medical  or  surgical,  between  the  sole 
attentions  of  an  average  doctor  of  half  a  cen- 
tury ago  or  an  average  nurse  of  to-day,  there 
would  be  simply  no  question  as  to  our  wisest  course. 
The  nurse  would  be  worth  fifty  of  the  doctor,  alike 
in  principles  and  in  details.  The  modern  nurse  has 
entered  into  the  heritage  of  modern  medical  and 
surgical  practice.  The  doctor  of  half  a  century  ago 
did  not  know  the  cause  of  inflammation ;  the  modern 
nurse  does.  That  one  fact  alone  establishes  an 
abyss  between  them.  He  was  in  the  dark  ages,  she 
in  the  light  of  to-day;  he  did  things  incessantly  and 
as  a  matter  of  course  which  in  her  eyes  would  be 
simply  criminal.  He  walked  along  the  hospital 
ward  and  used  one  and  the  same  sponge  for  all  the 
patients,  carrying  death  and  no  less,  in  his  hands; 


324  SURGERY  AND  SOCIETY 

and  she  has  learnt  to  do  otherwise.  Doubtless  she 
knows  less  than  the  modern  doctor,  doubtless  she 
must  obey  him,  but  in  the  absence  of  him  and  his 
orders  her  presence  in  the  house  means  the  presence 
of  skill  and  knowledge,  vastly  superior,  on  the 
whole,  to  any  skill  and  knowledge  whatever  which 
were  obtainable  upon  the  earth  less  than  two  gen- 
erations ago.  There  were  giants  indeed  in  those 
days  and  in  the  days  before  them.  There  may  be 
scarcely  any  men  or  women  to  rival  some  who  were 
living  then,  and  yet  it  is  asserted  that  the  first  nurse 
whom  you  choose  almost  at  random  by  telephone 
brings  with  her  knowledge  and  capacity  of  a  vital 
order  which  John  Hunter  had  not  nor  Astley  Cooper 
nor  James  Simpson. 

It  seems  absurd,  but  it  is  true.  Where,  indeed, 
would  progress  be,  as  we  understand  it,  if  such  as- 
sertions could  not  be  true?  This  is  the  meaning  of 
the  social  heritage.  There  are  fundamentals  of 
physics  and  astronomy,  of  chemistry  and  biology, 
which  are  familiarly  known  not  merely  to  the  ideal 
schoolboy  of  Macaulay  but  to  everyone  nowadays, 
yet  which  were  utterly  hidden  from  Aristotle  and 
Bacon.  We  stand  on  our  ancestors*  shoulders,  and 
consequently  see  further.  This  is  as  true  of  medi- 
cine as  it  is  of  any  other  science.  Yet  here  popular 
knowledge  lags  conspicuously  far  behind  that  of  the 
expert.  We  all  know  more  about  the  relations  of 
earth  and  sun  than  Aristotle  or  Bacon  did,  but  so 
far  as  the  causes  of  inflammation  are  concerned 
popular  opinion  is  no  better  informed  to-day  than 
ever  in  the  past.     The  modern  nurse,  however,  has 


THE  MODERN  NURSE  325 

entered  into  this  part  of  the  social  heritage  as  the 
public  at  large  has  not,  and  until  the  elementary 
facts  of  the  medical  sciences  are  taught  as  the  ele- 
mentary facts  of  other  sciences  should  be,  the  mod- 
ern nurse  in  an  average  house  is  the  twentieth  cen- 
tury come  to  the  rescue  of  the  tenth. 

Those  who  know  the  real  importance  and  dignity 
of  this  great  modern  profession,  and  the  extent  to 
which  the  realisation  of  the  practical  value  of  med- 
ical and  surgical  knowledge  depends  upon  the  nurse, 
are  bound  to  concern  themselves  in  every  possible 
way  with  raising  the  status  and  the  qualifications  of 
her  who  fulfils  such  a  great  function  for  the  modern 
state.  It  need  scarcely  be  said  that  the  first  and 
plainest  of  indications  is  the  establishment  of  some 
means  whereby  the  qualified  nurse  may  be  distin- 
guished from  the  unqualified.  It  has  not  yet  been 
possible  to  get  public  opinion  to  assent  to  legisla- 
tion prohibiting  medical  practice  on  the  part  of  un- 
qualified persons,  and  it  would  be  absurd  to  ask  for 
any  such  prohibition  in  the  case  of  unqualified 
nurses;  at  any  rate  so  far  as  ordinary  sick-nursing  is 
concerned.  But  it  is  certainly  reasonable  that  the 
nurse  who  has  faithfully  qualified  herself  for  her 
task  at  the  expenditure  of  much  time  and  money  and 
labour  should  be  distinguishable  from  the  first  per- 
son who  chooses  to  don  a  nurse's  uniform,  though 
her  medical  knowledge  be  simply  the  medical  igno- 
rance of  the  general  public.  I  certainly  plead  here, 
therefore,  for  the  State  Registration  of  trained 
nurses.  We  began  this  chapter  by  admitting  that 
the  nurse  is  born  as  well  as  made,  and  that  no  kind 


326  SURGERY  AND  SOCIETY 

of  hall-mark  certifying  to  the  making  process  can 
guarantee  the  first  condition.  That,  however,  is  no 
reason  whatever  for  questioning  the  Tightness  of 
training  and  of  identifying  the  trained. 

If  the  foregoing  applies,  as  it  does,  to  nursing  in 
general,  there  is  one  department  of  nursing  to  which 
it  applies  a  thousandfold,  since  therein  the  differ- 
ence between  knowledge  and  ignorance  constantly 
proves  itself  to  be  the  difference  between  life  and 
death.  I  refer,  of  course,  to  obstetric  nursing.  We 
may  briefly  remind  ourselves  that  childbirth  is 
normally  a  physiological  process  requiring  very  little 
assistance,  but  that  it  always  involves  pathological 
risks,  and  that  these  are  incalculably  multiplied  if 
the  mother  be  assisted  without  knowledge.  It  is  no 
doubt  ideally  desirable  that  every  mother  should  be 
tended  by  a  doctor  of  one  sex  or  other.  It  would 
be  absurd  to  assert,  however,  that  that  is  necessary 
in  the  great  majority  of  cases.  Nevertheless  there 
is  a  minimum  demand  which,  in  the  interests  of 
motherhood  —  and  therefore  of  everything  else  — 
may  be  formulated  and  must  some  day  be  complied 
with.  It  is  that  every  mother  should  be  attended 
at  childbirth  by  someone  conversant  with  Listerism. 
The  obstetric  nurse  or  the  midwife  —  it  really  mat- 
ters but  little  by  which  name  we  call  her  —  will 
doubtless  be  none  the  worse  for  knowing  something 
of  obstetrical  diagnosis,  especially  as  the  responsi- 
bility will  rest  with  her  of  sending  for  a  doctor 
should  occasion  arise.  In  the  not  distant  future 
every  woman  in  her  critical  hour  will  be  so  attended. 
Meanwhile,   I  make  a  lesser  yet  all-important  de- 


THE  MODERN  NURSE  327 

mand.  It  is  simply  that  the  attendant,  whether  her 
obstetric  knowledge  be  great  or  small,  must  be  a 
practising  Listerian.  If  she  be  not  this,  no  other 
qualifications  can  compensate  for  the  lack  of  this 
vital  need.  It  has  to  be  admitted,  therefore,  that 
according  to  this  demand  of  ours,  a  vast  host  not 
merely  of  midwives,  qualified  or  unqualified,  but  of 
actually  registered  and  practising  doctors,  would  be 
dismissed  from  all  further  opportunities  of  obstetric 
practice.  The  bare  record  of  the  number  of 
mothers  whose  lives  are  lost  in  England  and  Wales 
alone  every  year  because  someone  has  infected  them 
in  defiance  of  Listerian  principles,  would  suffice  to 
show  that  this  demand  of  ours  is  very  far  from  be- 
ing complied  with,  and  that  compliance  with  it 
would  mean  the  saving  of  thousands  of  mothers' 
lives  in  this  country  alone  every  year. 

None  of  these  deaths  should  occur.  They  are 
essentially  homicidal.  The  most  precious  part  of 
the  community,  in  the  performance  of  its  supreme 
task,  is  destroyed  in  thousands  of  instances  yearly 
because  knowledge  which  is  now  more  than  a  gener- 
ation old  is  defied  by  the  ignorant  or  careless.  The 
time  will  come  when  every  fatal  case  of  what  is 
called  puerperal  fever  will  be  the  subject  of  an  offi- 
cial enquiry,  and  sooner  still  the  time  will  come 
when,  whatever  may  be  permitted  as  regards  un- 
qualified medical  practice  in  general,  none  but  the 
qualified  will  be  allowed  to  attend  upon  childbirth. 
For  Great  Britain  the  recent  Midwives'  Act  has 
gone  far  in  this  direction. 

Here  is  another  instance  of  the  manner  in  which 


328  SURGERY  AND  SOCIETY 

moralists  of  many  schools  permit  themselves  to 
descant  vainly  in  one  direction  when  their  help  is 
needed  in  another.  There  is  no  mark  at  which  the 
moralist  more  commonly  aims  nowadays  than  the 
fall  in  the  birth-rate.  It  falls  and  continues  to  fall 
in  spite  of  him,  and  I  doubt  whether  all  his  railings 
have  yet  aided  a  single  unit  to  the  population.  Yet 
if  he  were  wise  he  would  direct  his  attention  to  the 
scandalous  conditions  of  the  existing  birth-rate;  to 
the  neglect  and  maltreatment  of  motherhood  and 
infancy.  We  who  have  undertaken  this  task  have 
already  added  to  the  population  scores  of  thousands 
of  infants  who  would  otherwise  have  died.  This  is 
not  raising  the  birth-rate  nor  arresting  its  decline, 
but  it  is  furthering  the  end  for  which  birth  occurs. 
Let  these  moralists  turn  from  a  phenomenon  which 
they  cannot  affect  and  devote  themselves  to  the  prac- 
ticable aspect  of  the  same  subject  —  to  the  safe- 
guarding and  ennobling  of  motherhood  and  infancy. 
This  is  a  great  task  with  many  factors,  but  one  of 
them  assuredly  is  the  provision  of  Listerian  ob- 
stetrics for  every  mother  in  the  land. 

We  must  encourage  women  of  the  best  type  to 
enter  this  great  profession  of  obstetric  nursing;  we 
must  realise  that  this  is  worth  our  while  from  the 
national  point  of  view,  and  that  the  labourer  is 
worthy  of  her  hire.  She  must  be  available  to  every 
mother.  Obstetric  complications  and  accidents  will 
occur,  no  doubt,  in  some  degree  to  the  end  of  time, 
but  puerperal  infection  must  end  in  the  homes  of 
the  poor,  as  it  has  ended  already  in  the  homes  of  the 
well-to-do  and  in  Maternity  Hospitals.     It  might 


THE  MODERN  NURSE  329 

once  have  been  argued  that  the  infection  cannot  be 
avoided  in  the  homes  of  the  poor  because  of  the 
sanitary  conditions  which  there  prevail.  But  not  so 
long  ago  it  was  in  the  Maternity  Hospitals  that  the 
infection  could  not  be  avoided.  The  truth  is  that 
not  the  sanitary  conditions  in  general  but  the  im- 
mediately local  conditions  determine  the  occurrence 
or  prevention  of  infection.  There  is  no  more  need 
for  puerperal  fever  to  occur  in  any  one  place  than 
in  any  other.  The  crucial  factor  is  the  personal 
attendant  of  the  lying-in  mother,  or  especially  may 
we  say  the  hands  of  that  special  attendant.  The 
same  —  but  greater  —  importance  attaches  to  them 
as  to  the  hands  of  the  operating  surgeon  and  for 
precisely  the  same  reason.  The  very  same  species 
of  microbes,  indeed,  which  are  to  be  feared  in  the 
one  case  are  to  be  feared  in  the  other.  Now  the 
hands  of  the  surgeon  or  of  the  obstetric  nurse  may 
be  infected  according  to  what  has  been  done  with 
them,  either  in  a  Maternity  Hospital  or  in  a  palace 
or  in  a  hovel,  and  they  can  be  efficiently  disinfected 
in  any  of  these  places.  Everywhere  the  essential  is 
responsible  knowledge  —  knowledge  which  is  now 
obtainable,  and  the  practical  application  of  which  is 
not  expensive. 

The  present  incidence  of  puerperal  fever  in  the 
land  of  Lister  is  a  great  scandal.  We  are  fully  en- 
titled to  assert  that  there  should  be  no  such  thing. 
Doctors  and  nurses  who  practise  their  profession 
as  they  should  go  through  their  entire  careers  with- 
out having  a  single  case;  others  carry  death  in  their 
hands  wherever  they  go.     They  should  be  put  a 


330  SURGERY  AND  SOCIETY 

stop  to.  It  must  be  remembered  that  not  merely 
the  deaths  of  thousands  of  mothers  is  to  be  reckoned 
as  the  consequence  of  failure  to  apply  Listerism  to 
obstetrics.  Very  often  the  loss  of  the  mother  means 
the  loss  of  the  child,  since  infant  mortality  is  so 
much  higher  amongst  infants  who  are  not  nursed 
at  the  breast.  Further,  the  destruction  of  so  many 
women  at  the  child-bearing  ages  necessarily  lowers 
the  birth-rate.  Thus  if  our  moralists  desired  to 
raise  the  birth-rate  as  it  should  be  raised,  they  would 
set  themselves  to  protect  mothers  from  such  condi- 
tions as  these  which  destroy  them,  and  their  efforts 
thus  directed  would  certainly  be  rewarded. 

Yet  further  be  it  noted  that  the  most  common  of 
all  the  exciting  causes  of  insanity,  according  to  the 
official  records  in  Great  Britain,  is  the  puerperal 
state.  The  shock  and  strain  incident  upon  child- 
birth disorganise  for  a  greater  or  longer  period  the 
mental  functions  of  a  large  number  of  mothers.  It 
need  scarcely  be  said  that,  as  we  should  expect, 
puerperal  infection,  failing  actually  to  kill  the  pa- 
tient, very  often  suffices  to  produce  insanity.  The 
shock  and  strain  of  normal  childbirth  are  relatively 
slight  as  factors  of  mental  disorganisation  when 
compared  with  the  same  conditions  supplemented 
by  the  absorption  into  the  blood  and  nervous  tissues 
of  poisons  derived  from  the  microbic  infection  which 
constitutes  puerperal  fever. 

It  will  thus  be  seen  that  the  application  of  Lister- 
ism to  obstetrics  by  means  of  the  obstetric  nurse  or 
midwife  will  involve  in  proportion  to  its  complete- 


THE  MODERN  NURSE  331 

ness  the  substantial  abolition  of  deaths  due  to  child- 
birth, the  overwhelming  majority  of  which  are  con- 
sequences of  puerperal  fever,  which  under  Listerism 
cannot  occur;  a  reduction  of  infant  mortality;  a  rise 
in  the  birth-rate,  other  things  being  equal;  and  a 
reduction  in  the  incidence  of  puerperal  insanity. 

It  will  be  seen  therefore,  that  the  obstetric  nurse 
stands  at  the  very  foundations  of  national  well-be- 
ing. Her  services  save  mothers  in  life  and  in  mind; 
they  save  infants;  and  they  increase  the  production 
of  infants.  As  the  birth-rate  persistently  declines, 
the  national  importance  of  births  will  steadily  be- 
come more  evident.  Attention  will  more  and  more 
be  directed  to  the  saving  of  babies  that  are  born  and 
of  those  who  produce  them.  Listerism  will  be  as 
triumphantly  applied  to  the  saving  of  life  in  the 
lying-in  room  as  upon  the  battle-field,  and  obstetric 
nursing,  which  is  indeed  the  highest  branch  of  the 
art,  will  receive  the  honour  which  is  its  due. 

To  this  chapter  a  few  supplementary  words  may 
be  added  regarding  a  special  function  of  the  ob- 
stetric nurse  which  Listerism  has  taught  her  to  dis- 
charge. Far  and  away  the  commonest  cause  of 
blindness  from  birth  is  inflammation  of  the  eyes,  due 
to  their  invasion  when  the  child  first  opens  them  at 
its  birth  by  a  certain  minute  organism  called  the 
gonococcus.  This  produces  an  intense  inflamma- 
tion of  much  the  same  order  as  that  for  which  many 
other  kinds  of  coccus  are  responsible.  It  is  tran- 
sient but  its  effects  are  permanent,  for  it  involves 
the  cornea  or  transparent  portion  of  the  front  of  the 


332  SURGERY  AND  SOCIETY 

eye,  and  in  the  course  of  the  healing  the  cornea  be- 
comes irremediably  opaque.  Listerism  has  indeed 
made  it  possible  for  one  recorded  eye,  at  any  rate, 
to  have  a  transparent  piece  of  cornea  substituted  by 
grafting  for  the  cornea  which  inflammation  had 
ruined.  Apart  from  that  case,  all  eyes  thus  de- 
stroyed are  destroyed  forever.  Now  we  know  for 
certain  that  this  appalling  disaster,  with  its  horrible 
cruelty  to  large  numbers  of  infants  all  the  world 
over,  and  with  its  lasting  consequences,  is  completely 
preventable  if  the  ordinary  principles  of  Listerism 
be  applied  to  the  baby's  eyes  directly  it  is  born. 
Every  modern  obstetric  nurse  regards  this  as  an  es- 
sential part  of  her  duties.  Within  a  few  seconds 
or  a  minute  or  two  at  latest  of  the  child's  birth,  its 
eyes  are  scrupulously  swabbed  out  with  an  antisep- 
tic lotion,  and  any  infection  which  may  have  entered 
them  is  thus  washed  away.  It  would  be  hard  to 
find  an  instance  where  a  simpler  and  easier  precau- 
tion averts  more  disaster  than  this.  It  follows  that 
there  are  many  thousands  of  seeing  persons  walking 
about  unaided  in  any  modern  community  who,  but 
for  Listerism,  would  be  blind.  Very  few,  indeed, 
we  must  understand,  of  those  who  were  asserted  to 
have  been  born  blind  were  born  other  than  normal 
as  regards  their  eyes.  The  eyes  were  infected  after 
their  birth;  in  most  cases  at  the  very  instant  when 
they  were  first  opened  to  the  light.  But  here  in  our 
day  Lord  Lister  intervenes,  and  the  eyes  are  saved. 
I  suggest  that  contributors  to  Blind  Asylums  and  those 
who  give  their  pennies  to  blind  people  in  the  streets 
should    consider    the    propriety    of    devoting    their 


THE  MODERN  NURSE  333 

sympathy  and  their  means  primarily  to  the  pro- 
vision of  good  Listerian  nursing  for  all  mothers  and 
for  the  eyes  of  all  babies  that  are  born  into  the 
world. 


CHAPTER  XV 

THE  ABUSE  OF  LISTERISM 

Every  new  access  of  human  power,  of  whatever 
kind,  tests  the  fundamental  thinking  of  the  genera- 
tion which  receives  it.  The  use  of  steam  and  wheels 
for  industrial  purposes  leads  to  the  evils  of  industri- 
alism, and  people  desire  the  return  of  the  "  good 
old  days "  before  such  things.  Aeroplanes  and 
submarines  are  used  for  military  purposes,  or  for 
"  sport "  with  money  in  it,  and  we  wonder  whether 
these  "  fiendish  inventions  "  are  worth  while.  As 
we  are  about  to  see,  the  same  objections  may  be 
raised  even  against  Listerism. 

If  we  are  to  keep  our  heads  in  such  times  as  ours 
we  must  hold  hard  by  one  certain  and  fundamental 
proposition,  which  is  true  of  all  forms  of  power, 
and  most  evidently  true  of  that  form  of  power 
which  we  call  knowledge.  This  is  the  proposition 
that  no  kind  of  power  or  capacity  is  good  or  evil 
in  itself:  to  which  may  be  added  the  proposition, 
less  evident,  indeed,  yet  certain,  that  the  good  will 
outweigh  the  evil  in  the  long  run.  Dynamite  may 
entomb  or  untomb ;  radium  may  cause  cancer  or  cure 
it;  light  may  give  life  or  death;  alcohol  may  be  used 
outside  the  body  or  abused  inside  it;  the  knife  may 
kill  or  cure ;  money  may  be  a  root  of  all  evil  or  a  root 

334 


THE  ABUSE  OF  LISTERISM  335 

of  all  good;  intellect  may  curse  mankind  with  a 
Napoleon  or  bless  it  with  a  Pasteur. 

The  fruit  of  the  tree  of  knowledge  is  both  good 
and  evil;  and  the  argument  against  any  kind  of 
knowledge  or  power  may  be  turned,  if  it  be  once 
admitted,  against  all  kinds  of  knowledge  or  power. 
But  it  cannot  be  admitted,  for  the  evident  reason 
that  power  is  non-moral,  and  may  be  indifferently 
turned  to  good  or  evil  ends.  The  business  of  those 
who  wish  the  good  is  to  turn  all  forms  of  power 
more  and  more  to  that  end,  convinced  that,  if  they 
will,  there  may  be  good  in  everything. 

Before  we  come  to  our  special  subject,  the  fore- 
going argument  may  be  illustrated,  and  the  im- 
portance of  first  principles  gauged,  by  reference  to 
one  or  two  recent  instances,  where  the  rapid  achieve- 
ments of  man's  intellect  have  outstripped  his  ca- 
pacity for  moral  and  emotional  adjustment.  It  is 
perfectly  evident  that  the  discovery  of  the  means 
whereby  neo-Malthusianism  so-called  may  be  safely 
practised,  is  one  which  may  be  and  often  is  turned 
to  immoral  ends;  and  the  recognition  of  this  fact, 
together  with  the  feeling  that  the  device  is  unnat- 
ural (as  if  every  human  invention,  cooking  or  a 
wheel  or  a  tool,  were  not  "unnatural''!)  leads 
many  to  condemn  this  form  of  knowledge  entirely. 
Yet  a  case  for  the  legitimate  and  valuable  use  of 
neo-Malthusianism  may  be  stated.  Again,  there 
was  much  outcry,  not  many  years  ago,  when  Prof. 
Metchnikoff  devised  a  medicament  which  offered  a 
considerable  measure  of  protection  against  forms  of 
disease  which  are  commonly  associated  with  loose 


336  SURGERY  AND  SOCIETY 

living:  though  it  is  easy  to  find  cases,  say  in  the 
finger  of  a  surgeon  infected  in  doing  his  duty,  where 
Metchnikoff's  device  may  be  turned  to  good  ends. 
It  is  significant  of  the  development  of  public  opinion 
that,  so  far  as  one  can  observe,  the  so-called  moral 
objections  to  Metchnikoff's  work  have  received  no 
expression  in  connexion  with  the  work,  a  few  years 
later,  of  Ehrlich,  in  the  production  of  a  rapid  thera- 
peutic agency  against  the  same  infection.  But, 
whether  vocal  or  not,  there  will  be  many  to  believe 
that  the  new  forms  of  power  which  these  investi- 
gators have  placed  at  our  disposal  were  better  un- 
known, and  if  we  are  rightly  to  meet  such  objectors 
we  must  clearly  formulate  our  own  first  principles. 

All  this  by  way  of  an  introduction  to  the  question 
of  the  abuse  of  Listerism.  We  see  clearly  that  the 
possibility  of  this  abuse  involves  no  reflection  upon 
Listerism  itself,  any  more  than  the  possibility  of  sun- 
stroke compromises  the  beneficence  of  the  sustainer 
of  all  terrestrial  life.  Further,  we  must  be  by  now 
overwhelmingly  convinced  of  the  value  of  Listerism, 
and,  therefore,  may  freely  discuss  its  abuse  without 
fear  that  the  beam  may  fall  on  that  side,  and  with- 
out any  sense  of  disloyalty  to  man's  best  friend  in 
need. 

Obviously  there  must  be  many  ways  in  which  a 
power  so  great,  so  versatile,  and  confined  for  its 
wielding  to  so  few,  may  be  abused.  It  does  not,  in- 
deed, lend  itself  to  the  secret  purposes  of  the  mur- 
derer, except  in  one  way,  as  do  modern  bacteriology 
and    the    refinements    of   modern    materia    medica. 

But,  short  of  that,  Listerism  is  capable  of  all  kinds 


THE  ABUSE  OF  LISTERISM  337, 

of  abuse,  and  to  these  it  will  continue  to  be  turned 
until  many  radical  changes  are  made  in  the  present 
relations  between  the  medico-surgical  profession  and 
the  public. 

In  the  first  place,  Listerism,  capably  practised  by 
a  gynecologist,  offers  a  practically  safe  and  rapid 
means,  leaving  no  ill-traces,  of  performing  ante-natal 
infanticide.  This  operation  is  another  illustration  of 
the  difficulties  in  which  modern  powers  involve  our 
ethical  conceptions.  Sooner  or  later  we  must  look 
upon  it  as  one  which  practically  does  not  at  all  en- 
danger the  life  of  the  mother.  Listerism  makes  that 
difference:  and  our  ethical  judgment  must  accord- 
ingly be  determined  by  the  question  of  the  child. 
Notwithstanding  that  I  am  a  student  and  enthusiastic 
advocate  of  what  I  call  "  negative  eugenics,"  I  am 
quite  convinced  that,  even  when  Listerism  has  thus 
enabled  us  to  disentangle  the  issues,  ante-natal  in- 
fanticide must  be  wholly  condemned,  apart  from  the 
special  cases,  everywhere  approved  of,  in  which  local 
considerations  of  grave  disease  make  the  operation 
imperative  for  the  life  of  the  mother.  Apart  from 
such  cases  this  operation  is  to  be  condemned,  and 
is  particularly  to  be  noted  as  entirely  outside  the 
sphere  of  eugenics,  no  matter  how  degenerate  may 
be  the  young  life  in  question.  The  concern  of  eu- 
genics is  with  parenthood  and  selection  for  parent- 
hood, not  selection  for  life.  It  works  by  a  selective 
birth-rate,  not  a  selective  death-rate:  and  its  moral 
status  and  practical  success  are  immediately  and 
gravely  imperilled  directly  we  begin  to  propose,  in 
its  name,  the  taking  of  life  at  any  stage  whatever, 


338  SURGERY  AND  SOCIETY 

born  or  unborn.  No  decent  person  can  Have  any- 
thing but  contempt  for  the  blind  and  malignant 
cruelty  with  which  the  law  and  public  opinion  pursue 
the  young  mother  in  such  cases;  nor  can  those  who 
know  anything  of  working-class  life  very  well  refuse 
their  sympathy  to  the  overworked  wife  who  seeks 
the  aid  of  a  professional  murderess  of  the  unborn. 
But  when  this  has  been  recognised  we  may  still  be 
convinced  that  the  application  of  Listerism  to  these 
purposes  —  except  where,  for  instance,  the  develop- 
ment of  the  young  life  can  only  be  followed  by  its 
destruction  and  that  of  the  mother  —  is  an  abuse  of 
it,  rightly  to  be  condemned  and  prevented  by  the  law 
and  by  public  opinion.  There  occur,  every  day,  all 
over  the  world,  in  our  present  conditions  of  worse  than 
barbaric  defiance  of  eugenics,  cases  where  the  per- 
formance of  ante-natal  infanticide  would  be  the  lesser 
of  two  evils  —  lesser,  say,  than  the  birth  of  a  hope- 
less idiot  —  but  this  operation,  however  safe  it  may 
nowadays  be  to  the  mother,  is  not  to  be  permitted, 
because  the  admission  of  its  rightness  is  too  danger- 
ous, and  because  such  admission  would  prejudice  the 
universal  adoption  of  the  right  means  whereby  such 
calamities  as  the  addition  of  idiots  to  the  community 
may  be  averted.  Since  this  is  not  a  text-book  upon 
the  principles  of  eugenics,  I  must  turn  away  from 
further  discussion,  but  it  will  suffice  to  say  that  the 
new  life  which  is  not  desirable,  and  for  which  the 
best  conditions  are  not  to  be  provided,  should  not, 
and  some  day  will  not,  be  called  into  existence  at 
all. 

This   last   consideration   renders   necessary   some 


THE  ABUSE  OF  LISTERISM  339 

further  reference  to  the  operation  for  non-mutilative 
sterilisation,  by  section  or  ligature  of  the  germ-cell- 
bearing  ducts  in  either  sex,  which  offers  a  safe,  cer- 
tain, simple,  rapid,  permanent,  and  irrevocable 
means  of  interference  with  parenthood.  Brief  allu- 
sion has  been  made  to  this  operation  in  a  previous 
chapter.  Quite  evidently  it  may  produce  the  same 
result,  in  the  long  run,  as  the  performance  of  ante- 
natal infanticide  —  which  I  suggest  to  be  the  proper 
title  for  the  operation  which  has  just  been  con- 
demned. That  result  is,  however,  by  no  means  nec- 
essarily an  evil  one,  and,  therefore,  every  means 
thereto  requires  ethical  judgment  on  its  own  merits. 
Continence  interferes  with  conception,  and  so  do 
economic  facts  which  delay  marriage:  but  these  are 
not  necessarily  to  be  condemned.  The  production 
of  abortion  is  the  taking  of  life,  and  it  is  rightly 
condemned  by  the  law.  Avoidance  of  the  condi- 
tions which  are  necessary  for  the  making  of  life  is 
evidently  in  a  totally  distinct  category.  Thus  we 
find  that,  whilst  all  civilised  States  penalise  the  pro- 
duction of  abortion  except  in  order  to  save  the  life  of 
the  mother,  at  least  one  State,  that  of  Indiana,  author- 
ises the  performance  of  sterilisation  upon  certain 
kinds  of  criminals.  The  minds  of  thoughtful  peo- 
ple are  indeed  probably  convinced  by  now  that  there 
may  be  cases  where  this  operation  is  justifiable,  if  not 
even  demanded  by  justice,  and  the  case  need  not  be 
further  argued  here. 

Most  obviously,  however,  there  is  here  a  possi- 
bility of  the  abuse  of  Listerism.  That  has  been 
quite  evident  to  those  who,  like  the  present  writer, 


340  SURGERY  AND  SOCIETY 

have  now  for  many  years  advocated  sterilisation  as 
a  measure  of  negative  eugenics  in  certain  cases.  It 
was  plain  that,  when  men,  in  particular,  became 
aware  of  the  facts  of  vasectomy,  many  of  them  would 
seek  to  have  the  operation  performed  upon  them- 
selves, and  that  both  married  and  unmarried  per- 
sons, of  both  sexes,  might  seek  to  have  recourse  to 
sterilisation.  I  am  now  credibly  informed  that  which 
was  certain  to  happen  is  already  happening  in  the 
United  States  of  America,  where  the  Indiana  pro- 
vision has  acquainted  the  public  very  widely  with 
the  possibilities.  In  Great  Britain  one  still  has  to 
explain,  on  every  occasion,  that  sterilisation  is  not 
emasculation  or  defeminisation.  On  the  other  side 
of  the  Atlantic  the  precise  and  narrow  consequences 
of  the  operation  are  known,  and  an  American  ob- 
server who  gave  me  the  results  of  his  experience 
in  connexion  with  my  paper  on  eugenics  at  the  First 
National  Conference  on  the  Prevention  of  Destitu- 
tion, assured  me  that  many  men  were  now  seeking 
and  finding  surgeons  for  the  performance  of  this 
operation.  In  many  cases  the  operation  would  be 
justifiable  according  to  my  eugenic  creed.  But  in 
many  others  it  will  be  evident  that,  in  more  ways 
than  one  or  two,  its  performance  must  be  an  abuse 
of  Listerism. 

Plainly  the  feasibility  of  this  procedure,  and  the 
general  acquaintance  with  the  facts,  opens  a  new 
era  in  the  matter  of  sex-relations.  That  is  a  large 
statement,  but  time  will  justify  it.  The  operations 
of  vasectomy  and  salpingectomy  are  often  performed 
for  other  purposes  than  sterilisation.     They  are  not' 


THE  ABUSE  OF  LISTERISM  341 

illegal  and  never  will  be  illegal.  Like  other  im- 
mense powers  of  man  —  for  these  are  immense,  stu- 
pendous powers  —  these  may  be  turned  to  great 
good  or  great  evil,  used  or  abused  in  proportion  to 
their  magnitude.  I  believe  that  in  this  sensational 
and  staggering  new  case,  the  good  will  ultimately 
outweigh  the  evil,  if  not  at  first.  It  will  behove  us 
to  keep  our  heads. 

The  sterilisation  is  irrevocable,  and  final,  a  fact 
which  sharply  differentiates  it  from  what  is  called 
neo-Malthusianism.  The  young  man  who  has  it 
performed  upon  himself  for  his  nefarious  purposes 
will  never  become  a  father;1  and  even  though  his 
condition  as  a  bachelor  may  prove  to  be  the  physical 
salvation,  in  some  degree,  if  to  the  moral  undoing, 
of  women,  it  must  assuredly  be  made  known  before 
he  marries.  The  law  will  require  to  grant  a  woman 
immediate  dissolution  of  marriage  if  it  be  shown 
that  her  husband  has  had  this  operation  performed 
upon  him. 

There  are  many  beastly  men  all  the  world  over, 
who  will  live  a  beast's  life,  as  the  saying  should  be 
but  is  not,  in  any  case.  The  surgeon  may  well  ques- 
tion whether  it  is  not  a  service  to  the  present  and 
the  future  to  assent  to  such  men's  request  for  steril- 
isation. We  desire  neither  their  illegitimate  nor 
the  legitimate  children:  but  no  woman  must  be  de- 
ceived into  marrying  a  man  who  is  such  that  her 
marriage  will  deprive  her  of  the  chance  of  mother- 
hood.    The  reader  who  begins  to  realise  the  com- 

i-The  continuity  of  the  ducts  has  lately  been  reestablished  after 
the. performance  of  this  operation  in  the  United  States  of  America. 


342  SURGERY  AND  SOCIETY 

plexity  and  magnitude  of  the  questions  here  involved 
should  read  the  three  plays  of  M.  Brieux  recently 
introduced  to  English  readers  by  Mr.  Bernard  Shaw. 
Les  A  varies  (now  translated  as  "  Damaged 
Goods  "),  which  I  have  so  long  commended  to  Eng- 
lish readers,  does  not  bear  upon  this  question  of 
sterilisation,  but  Maternhe  and  Les  Trots  Filles  de 
Mme.  Angot  do;  and  one  is  the  more  likely  after 
reading  them,  to  be  wisely  prepared  for  that  recon- 
struction of  sexual  morality  and  practice  which  alone 
can  save  our  civilisation  from  the  fate  of  all  its  pred- 
ecessors. To  that  reconstruction  Listerism,  no 
longer  abused,  will  contribute. 

Yet  another  abuse  of  Listerism  is  now  decadent. 
The  time  has  passed  when  operators  freely  exploited 
their  new  powers  by  the  extirpation  of  the  ovaries, 
careless  of  remote  consequences.  At  one  time  this 
had  become  a  serious  scandal.  The  operator  was 
not  a  physiologist,  and  had  no  clear  idea  of  the  unity 
and  interdependence  of  bodily  structures.  If  it  was 
evidently  necessary  to  remove  one  ovary,  and  the 
other  was  in  a  doubtful  condition,  why  not  remove 
that  also  ?  The  new  power  which  Lister  had  placed 
in  the  hands  of  surgeons  was  too  wonderful  not  to 
be  exploited  beyond  the  limits  of  lasting  utility. 
But  of  course  the  time  came  when  the  physiology  of 
the  ovaries  was  better  understood,  and  when  their 
importance  in  contribution  to  the  femininity  and  the 
health  and  happiness  of  woman  came  to  be  recog- 
nised. No  sooner  did  surgeons  in  general  come  to 
realise  what  they  were  doing  than  this  abuse  fell  into 
abeyance. 


THE  ABUSE  OF  LISTERISM  343 

The  most  serious  abuse  of  Listerism  at  the  present 
time  depends  upon  economic  causes,  and  can  be  un- 
derstood only  if  we  study  the  very  singular  and 
anomalous  relations  of  the  surgeon  to  the  public  so 
far  as  money  is  concerned.  Briefly,  it  may  be  said 
that,  on  the  one  hand,  surgeons  do  a  great  deal  of 
highly-skilled  and  valuable  work  for  nothing,  and 
that,  on  the  other  hand,  they  are  absurdly  overpaid 
when  they  are  paid  at  all. 

This  overpayment  depends  upon  many  causes. 
For  instance,  there  is  the  still  remaining  tradition 
that  a  surgical  operation  is  a  rare  and  tremendous 
feat,  which  only  a  rare  and  consummate  genius  can 
perform,  and  which  must  be  paid  for  accordingly. 
Again,  the  surgeon  must  maintain  his  fees,  or  his 
ostensible  fees,  at  the  highest  possible  figure,  in  order 
that  the  public,  which  has  no  other  criterion,  may 
estimate  him  accordingly,  or  in  order  that  he  may 
be  able  to  charge  it  on  the  rare  occasions  when  a 
very  wealthy  patient  comes  his  way.  But  other 
causes  of  this  overpayment  are  more  serious  and  ef- 
fective still. 

The  surgeon  devotes  the  greater  part  of  his  time 
to  entirely  unpaid  work.  Several  mornings  or  after- 
noons in  the  week  he  will  visit  the  hospital  and  per- 
form, say,  a  thousand  pounds'  worth  of  operations 
for  which  he  receives  nothing.  When,  therefore, 
he  gets  a  paying  patient,  he  is  compelled  to  charge 
as  high  a  figure  as  possible.  The  economic  fact  is 
that  the  paying  patients  pay  for  the  hospital  pa- 
tients; and  though  this  is  a  form  of  charity,  it  is  a 
highly  undesirable  one,  which  injures  all  concerned, 


344  SURGERY  AND  SOCIETY. 

as  we  shall  see.  Its  full  measure  can  only  be  appre- 
ciated, however,  if  we  realise  that  the  surgeon  com- 
monly has  to  wait  many  years,  doing  unpaid  work 
all  the  time,  before  he  gets  paying  patients,  and  that 
this  period  of  harvest,  for  which  he  has  been  pre- 
paring for,  say,  twenty  years,  only  lasts  for  ten  or 
fifteen.  The  patients  whom  he  can  obtain  in  that 
brief  remunerative  period  must  pay  for  all  the  un- 
paid work  which  the  surgeon  still  performs,  and  for 
all  the  years  of  education  and  unpaid  work  which 
preceded  it.  Of  course  the  whole  basis  of  such  a 
system  is  rotten,  and  it  cannot  last  much  longer. 

But  whilst  it  does  last,  it  does  abundance  of  harm. 
The  patients  who  get  their  surgery  for  nothing  are 
demoralised,  in  large  degree,  as  anyone  who  has 
first-hand  experience  of  hospitals  will  admit.  Nu- 
merous patients  who  could  afford  a  just  and  reasona- 
ble fee,  but  cannot  rise  to  the  level  of  the  surgeon's 
present  demand,  pocket  their  pride  and  avail  them- 
selves, in  the  hospital,  at  no  expense  at  all,  of  services 
for  which  they  would  otherwise  have  had  to  pay  an 
exorbitant  sum  outside.  They  must  either  pay  noth- 
ing —  which  is  much  too  little, —  or  else  a  great  deal 
too  much.  This  is  not  good  for  them  or  for  any- 
body; and  its  causation  must  be  remembered  when 
we  are  discussing  the  evergreen  problem  of  hospital 
abuse. 

The  arrangement  also  harms  those  who  do  pay, 
for  it  robs  them,  and  it  often  induces  them  to  delay 
or  to  forgo  an  operation  which  is  immediately  neces- 
sary. 

Finally,   it  is   calculated  to   injure   the   surgeon. 


THE  ABUSE  OF  LISTERISM  345 

This  invaluable  and  highly-skilled  member  of  so- 
ciety, beside  whom  it  is  hard  to  name  anyone  for 
utility  and  beneficence,  finds  himself  in  such  an  ex- 
traordinary economic  relation  to  those  whom  he 
serves,  that  he  can  neither  qualify  himself  to  do  so, 
nor  maintain  himself  whilst  doing  so,  unless  he  can 
somehow  obtain,  against  the  competition  of  a  large 
number  of  his  fellows  who  are  in  the  same  position,  a 
sufficient  number  of  patients  who  will  pay  him  huge 
operation  fees. 

Can  it  be  wondered  at,  in  such  circumstances,  that 
the  absolute  necessity  of  obtaining  such  fees  should 
sometimes  vitiate  the  surgeon's  judgment  as  to  the 
propriety  of  operating  at  all?  Far  be  it  from  any 
responsible  writer  to  suggest  that  a  large  propor- 
tion of  surgeons  fall  victims  to  the  evident  tempta- 
tion. But  a  few  of  them  undoubtedly  do,  nor  is  the 
fact  to  be  wondered  at.  It  does  not  necessarily  in- 
volve any  dishonesty.  Dishonest  men  there  will  be 
amongst  the  ranks  of  surgeons,  as  amongst  the  ranks 
of  bishops,  and  the  enemies  of  surgery  or  of 
episcopacy  will  make  the  most  of  the  fact,  which  is 
entirely  beside  the  point;  but  it  needs  very  little 
comprehension  of  surgical  problems  to  show  that 
the  moral  question  is  no  such  simple  one.  The  pa- 
tient consults  a  surgeon,  who  may  be  unable  to  diag- 
nose the  disease  with  certainty.  Time  may  clear  it 
up,  yet  time  may  be  appallingly  lost  in  so  doing. 
The  disease  may  be  one  which  requires  complete  re- 
moval, yet  the  surgeon  cannot  possibly  say  whether 
or  not  he  will  be  able  to  extirpate  it  entirely:  and 
something  short  of  extirpation  may  give  much  relief. 


346  SURGERY  AND  SOCIETY 

If  he  refrains  on  one  ground  or  another,  the  patient 
may  very  likely  go  to  a  second  surgeon,  who  may 
be  of  a  slightly  different  temperament,  preferring 
action  to  delay,  or  who  may  prefer  "  giving  the  pa- 
tient a  chance,"  or  who  may  consider  an  incomplete 
operation  very  well  worth  while  as  a  palliative.  If 
such  an  operation  is  to  be  performed,  why  should  not 
the  first  surgeon  be  the  operator? 

Thus  it  comes  about  that  the  door  is  opened  to  the 
abuse  of  Listerism,  by  the  performance  of  operations 
which  were  better  undone. 

Nevertheless  I  am  of  opinion  that  this  is  a  rapidly 
diminishing  evil.  Quite  evidently  our  estimate  of 
the  whole  question  depends  upon  the  results  of  oper- 
ation. Whenever  an  improvement  in  antiseptic  or 
aseptic  technique  makes  operations  safer,  so  much 
the  less  is  the  objection  to  unnecessary  operations. 
Whenever  an  improvement  in  anaesthesia  makes  the 
administration  of  anaesthetics  safer,  so  much  the  less 
does  it  matter  that  an  unnecessary  occasion  has  been 
presented  to  them.  And  whenever  improvement  in 
the  actual  technique  of  operation  adds  to  the  sur- 
geon's powers,  the  number  of  cases  in  which  he  can 
be  reasonably  certain  of  doing  at  any  rate  some  good 
increases.  It  follows  that  the  extraordinary  ad- 
vances of  the  last  ten  or  fifteen  years  have  vastly  re- 
duced the  abuse  of  Listerism,  for  the  simple  reason 
that  the  modern  surgeon  can  scarcely  fail  to  be  use- 
ful, in  some  measure  at  any  rate,  whenever  he  wields 
the  knife.  He  may  perform  less  than  he  promises, 
he  may  have  to  return  to  his  task,  he  may  charge 
very  heavy  fees  when  he  charges  any  fees  at  all,  but 


THE  ABUSE  OF  LISTERISM  347 

his  procedure  is  now  so  safe,  so  versatile  and  so 
skilful  that  he  very  rarely  indeed  fails  to  leave  the 
patient  better  than  he  found  him:  and  when  the 
chance  of  doing  harm  is  so  minute,  it  may  be  wrong 
to  deprive  the  patient  of  even  a  small  chance  of  do- 
ing good. 

Whilst  it  was  necessary,  then,  to  include  the  pres- 
ent chapter  in  our  discussion,  I  believe  the  reader 
may  be  reassured,  if  it  was  his  habit  to  suppose  that 
surgeons  are  sharks,  habitually  recommending  and 
performing  upon  others  operations  which  they  would 
not  undergo  themselves.  The  general  advance  of 
surgery  has  made  that  belief  impossible,  for  the 
simple  reason  that  it  would  probably  be  difficult  to 
find  10  per  cent,  of  the  community  who  would  not 
profit  by  surgical  attention  in  one  form  or  another 
—  say  in  the  matter  of  varicose  veins  in  one  situation 
or  another. 

If  we  desire  to  put  this  whole  question  on  such  a 
basis  that  the  temptation  to  abuse  may  be  reduced 
to  vanishing  point,  we  must  set  ourselves  to  the 
economic  question,  and  seek  to  obtain  and  to  dis- 
seminate sound  opinions  thereon,  so  that  the  public 
and  the  legislature  may  be  prepared  for  the  necessary 
and  urgent  changes  in  the  economic  relations  of  the 
surgeons,  the  public  and  the  hospitals.  Some  refer- 
ence has  already  been  made  to  this  subject,  but  it  de- 
mands a  special  chapter  if  we  are  to  see  our  way 
towards  such  reconstructions  as  will  provide  Lister- 
ism  for  all  who  need  it,  and  fair  remuneration  for 
its  practitioners.  When  the  present  volume  was  be- 
gun such  discussions  would  have   appeared  merely 


348  SURGERY  AND  SOCIETY 

Utopian,  but  the  introduction  of  a  great  system  of 
national  insurance  against  illness  is  about  to  make 
a  new  epoch  in  Great  Britain,  and  will  doubtless 
be  followed  in  all  civilised  countries.  The  medical 
profession  is  about  to  have  the  greater  part  of  its 
economic  relation  to  the  public  entirely  reversed, 
being  paid,  and  finding  it  pay,  to  keep  the  com- 
munity in  health;  and  under  the  new  conditions  we 
shall  assuredly  be  able  to  realise  the  ideal  which  this 
book  is  designed  to  serve  —  the  supply  of  Listerism, 
fairly,  promptly  and  unfailingly,  to  all  —  rich  and 
poor,  men,  women  and  children,  old  and  young, 
from  the  mothers  on  their  natural  thrones,  which  no 
revolutions  can  shake,  down  to  the  "  sportsmen  " 
who  accidently  injure  themselves  instead  of  some 
innocent  and  lovely  thing. 


CHAPTER  XVI 
THE  PROVISION  OF  LISTERISM 

The  foregoing  chapters  have  sadly  missed  fire  if  it 
has  not  been  made  abundantly  plain  that  surgery 
is  of  high  sociological  importance.  Disease  and  dis- 
ability are  social  facts  which  are  also  potent  social 
causes.  We  have  problems  of  destitution  and  its  con- 
sequences, for  instance,  which  all  preceding  genera- 
tions have  attempted  to  relieve,  and  now  we  begin 
to  see  that  destitution  can  be  prevented,  because, 
for  instance,  preventable  or  curable  disease  is  re- 
sponsible for  an  enormous  proportion  of  it.  The 
provision  of  Listerism  is  therefore  of  importance 
both  to  the  individual  and  to  the  citizen  who  is  con- 
cerned with  fundamental  politics.  It  may  at  any 
moment  intimately  concern  the  purse  of  any  one  of 
us;  and  even  when  we  are  quite  unaware  of  any 
such  concern,  it  may  be  doing  so  in  the  shape  of  rates 
and  taxes  required  for  dealing  with  social  phenomena 
which  the  due  provision  of  Listerism  would  have  pre- 
vented. 

The  provision  of  Listerism  now  depends  upon  an 
economic  grading  of  the  community,  and  may  be 
therefore  discussed  on  that  classification,  though  the 
results  are  very  far  from  what  might  have  been  an- 
ticipated. 

The  wealthy  few  have  little  or  nothing  to  com- 

349 


350  SURGERY  AND  SOCIETY 

plain  of  in  regard  to  the  provision  of  Listerism. 
Say  "  little  or  nothing  "  because  they  may  indeed 
complain  that  they  have  to  pay  very  high  fees  which 
would  not  be  demanded  or  necessary  if  the  practice  of 
surgery  were  placed  upon  anything  like  a  sound  and 
equitable  economic  basis.  But  of  course  these  fees 
involve  no  hardship  in  the  case  of  the  really  wealthy, 
and  for  the  rest  they  have  no  cause  of  complaint. 
The  best  skill  and  attention  in  the  world  are  at  their 
disposal,  and  they  are  sufficiently  instructed,  in  at 
any  rate  a  large  number  of  cases,  to  avail  themselves 
of  these  advantages  in  time.  The  wealthy  woman 
who  has  a  slight  swelling  in  her  breast  has  had 
friends  in  a  similar  case,  and  she  has  learnt  from 
their  too  often  tragic  experience  that  she  should  con- 
sult a  surgeon  at  once.  The  fee  of  two  guineas  is  of 
no  consequence,  and  she  does  not  delay  in  the  hope 
of  saving  it  —  unless  she  be  a  fool  indeed. 

Not  even  the  houses  of  the  wealthy,  as  we  have 
seen,  can  by  any  means  satisfy  the  demands  of  mod- 
ern Listerism:  but  specially  built  and  perfectly 
equipped  nursing  homes  are  available  at  any  rate  in 
the  great  cities,  and  to  these  the  wise  patient  who  is 
fortunate  enough  to  be  wealthy  will  gladly  consent 
to  be  removed. 

The  only  other  people  who  can  at  all  compare 
with  the  wealthy  few  in  these  respects  are  the  poor 
—  not  the  struggling  professional  man  or  the  inade- 
quately paid  clerk,  but  the  really  poor.  They  and 
they  alone  are  supposed,  at  any  rate,  to  avail  them- 
selves of  the  hospitals,  where  large  numbers  of  them 
obtain  for  nothing  the  services  of  the  same  surgeons 


THE  PROVISION  OF  LISTERISM         351 

who  serve  the  wealthy,  and  of  equally  competent 
nurses,  together  with  every  material  Listerian  pro- 
tection and  provision  which  money  can  buy. 

That  this  magnificent  provision  should  be  made 
for  the  poorest  does  honour  to  our  civilisation  as  do 
very  few  of  its  more  boasted  triumphs.  But  it  has 
many  unsatisfactory  features.  In  the  first  place,  the 
provision  is  inadequate.  There  are  not  enough  beds 
and  theatres  for  all  the  patients  who  need  expert 
surgical  help:  nor  can  there  be  so  long  as  the  eco- 
nomic basis  of  the  hospital  service  remains  what  it 
is,  and  the  causes  of  disease  demanding  surgical  in- 
terference persist.  Much  more  important,  how- 
ever, is  the  fact  that  it  is  entirely  left  to  the  ignorant, 
uninstructed,  or  disgracefully  misdirected  and  sus- 
picious poor  to  consult  the  surgeon.  Popular  edu- 
cation has  given  them  no  guidance  in  such  matters, 
neither  as  to  significant  symptoms,  nor  as  to  the  be- 
neficence of  surgery,  nor  as  to  the  conduct  of  hospitals, 
nor  as  to  the  importance  of  taking  disease  in  time. 
The  fashion  in  which  the  poor  neglect  their  teeth 
is  a  simple  and  typical  illustration.  Thus  it  follows 
that  the  finest  surgical  skill  in  the  world,  the  most 
generous  provision  of  superb  theatres  on  the  part 
of  philanthropic  donors,  and  the  whole  apparatus 
of  a  modern  hospital  are  constantly  set  to  hopeless, 
futile,  or  semi-futile  tasks,  being  robbed  of  all  or 
half  their  efficacy  because  they  are  not  employed  in 
time. 

This  point  is  tragically  familiar  to  all  who  have 
any  hospital  experience,  in  such  common  cases  as 
cancer  and  surgical  tuberculosis,  where  time  is  of 


352  SURGERY  AND  SOCIETY 

the'  essence  of  the  problem ;  and  when  we  remember 
how  often  the  poor  are  misinformed  —  as  by  the 
anti-vivisectionists  —  and  decline  to  avail  themselves 
of  the  surgeon's  help  even  when  they  have  con- 
sulted him,  we  shall  realise  that  not  even  the  pro- 
vision of  skill  and  service  and  everything  else  suf- 
fices without  some  kind  of  machinery  acting  outside 
the  hospitals. 

That  machinery  will  in  a  large  measure  be  pro- 
vided in  Great  Britain  by  the  system  of  national 
insurance.  The  greater  part  of  the  patients  who 
belong  to  the  class  now  under  discussion  will  be  so 
insured  that  they  have  a  doctor  to  consult  even  for 
merely  suspicious  or  inconvenient  symptoms.  In- 
stead of  waiting  until  the  symptoms  become  intoler- 
able they  will  consult  a  doctor  at  once,  just  like  the 
well-to-do.  I,  therefore,  anticipate,  as  one  immedi- 
ate result  of  national  insurance  against  illness,  a 
great  increase  in  the  proportion  of  patients  whom 
hospital  surgeons  see  in  time.  But  only  surgeons 
themselves  can  adequately  estimate  the  value  to  their 
patients  and  the  satisfaction  to  themselves  of  such 
a  change,  which  will  mean  that  much  of  their  skill  and 
labour,  now  thrown  away  because  deprived  of  a  fair 
chance,  will  be  made  really  available  for  life  and 
for  health. 

An  immediate,  though  for  the  best  of  reasons  by 
no  means  a  lasting,  result  of  the  establishment  of  a 
system  of  national  insurance  must  therefore  be  a 
considerable  increase  in  the  pressure  upon  the  sur- 
gical wards  and  theatres  of  hospitals  —  an  in- 
crease which  must  hasten  the  inevitable  change  in 


THE  PROVISION  OT  LISTERISM         353 

the  economic  basis  of  these  institutions.  That  this 
change  is  indeed  inevitable  we  shall  realise  when  we 
proceed  to  consider  the  provision  of  Listerism  for  the 
great  middle-class,  which  can  neither  afford  the  fees 
of  the  best  surgeons  nor  bring  itself  to  enter  the 
hospitals,  even  if  patients  of  this  class  were  expected 
there. 

As  everyone  knows  very  well,  surgical  provision 
for  this  class  does  not  exist.  Even  the  consultation 
fees  of  two  guineas  for  a  first  and  one  for  subsequent 
visits,  are  a  serious  matter,  but  the  expense  of  an 
operation  together  with  nursing  and  incidentals  is 
ruinous.  What  the  poor  may  get  for  nothing  would 
cost  the  middle-class  man  perhaps  two  hundred 
pounds,  which  may  be  a  year's  income  —  say  of  a 
curate  or  clerk  or  what  not. 

We  shall  see  in  the  next  chapter  that  before  many 
decades  are  past  these  difficulties  will  have  settled 
themselves  in  the  best  of  all  imaginable  ways,  but 
for  some  years  to  come  they  demand  a  more  direct 
solution  than  by  the  progress  of  bio-chemistry  and 
bacteriology.  Adequate  and  just  provision  must  be 
made  for  all  classes  and  all  individuals  —  not  merely 
the  millionaire  and  the  pauper,  but  for  all  who  lie 
between  those  extremes.  This  provision  must  not 
be  made,  and  indeed  cannot  be  made,  at  the  cost  of 
surgeons.  No  profession  can  compare  for  a  mo- 
ment with  theirs  for  the  value  and  extent  of  the  serv- 
ices which  they  render  to  the  State  for  nothing;  but 
this  is  indeed  a  dangerous  form  of  charity,  very  apt 
to  injure,  in  subtle  but  real  ways,  him  that  gives  and 
him  that  takes. 


354  SURGERY  AND  SOCIETY! 

This  arrangement  whereby  the  best  surgeons  — 
since  they  alone  get  the  practice  they  are  bound  to 
be  on  the  average  the  best  surgeons  —  give  the 
greater  part  of  their  time  to  the  poor,  lacks  many 
of  the  aspects  of  true  charity.  It  is  indeed  imposed 
upon  their  giver.  He  must  have  his  hospital  con- 
nexion if  he  is  to  have  his  private  connexion,  both 
for  experience  and  for  reputation,  and  for  the  chance 
of  teaching  students  who  will  subsequently  send  their 
cases  to  him.  The  charity  is,  therefore,  more  appar- 
ent then  real  to-day:  and  the  allegation  is  none  the 
less  reasonable  if  we  remember  the  quite  outrageous 
fees  which  the  surgeon  obtains  whenever  he  can  — 
fees  which  physicians  of  corresponding  status  and 
skill  and  usefulness  never  dream  of  asking.  But 
these  outrageous  fees  are  the  hope  and  the  reward 
of  the  hospital  surgeon  who  definitely  accepts  that 
career;  and  the  work  he  does  for  nothing  must  be 
understood  accordingly. 

But  this  is  not  the  only  argument  against  the  ar- 
rangement which  deprives  the  middle-classes  of  the 
best  surgery  at  a  fair  price  and  demands  unfair  prices 
from  the  wealthy.  For  we  are  just  beginning  to 
perceive  that  the  whole  theory  of  charity  (of  the 
right,  constructive,  preservative  kind)  as  a  service 
rendered  for  love  to  individuals,  is  imperfect. 
"  England  has  need  of  men  " :  every  State  has  need 
of  men  and  women.  The  surgeon  who  accurately 
sets  the  workman's  broken  limb,  or  saves  his  sight, 
or  his  teeth,  is  not  merely  serving  his  patient.  He 
is  serving  the  State,  the  King,  if  you  will,  even  the 
rate-payer.     The  community  to-day  is  not  an   ag- 


THE  PROVISION  OF  LISTERISM         35^ 

gregate,  if  it  ever  was,  but  an  organism.  The  daily 
work  of  the  hospitals  may  be  looked  upon  as  charity 
from  one  aspect,  and  is  certainly  charity  so  far  as 
generous  donors  are  concerned.  But  it  is  also  con- 
structive politics,  of  a  reality  such  as  is  very  seldom 
approached  upon  the  floor  of  our  legislative  chambers. 
The  surgeon  is  a  great  servant  of  society:  the  mas- 
ter-surgeon, who  achieves  some  beneficent  innovation, 
is  no  less  high  and  illustrious  a  servant  of  the  State 
than  a  "prancing  proconsul"  or  a  Judge  of  the 
High  Court.  It  might  very  well  be  argued  that  the 
extraordinary  crassness  and  blindness  of  the  medical 
profession  as  a  whole  to  the  social  and  sociological 
idea  is  as  much  responsible  as  the  public  stupidity 
for  the  fact  that  these  assertions  are  not  the  stalest 
platitudes.  But  whatever  the  explanation  be,  there 
is  the  fact  that  the  exalted  function  of  Listerism  in 
the  modern  State  is  appreciated  nowhere,  least  of 
all,  perhaps,  by  surgeons  themselves.  Until  it  is 
recognised,  the  provision  of  Listerism  will  never  be 
adequate,  nor  surgeons  and  surgery  held  in  the  hon- 
our which  is  their  due,  or  would  be  their  due  if  they 
were  not  still  imbued  with  the  individualism  of  half 
a  century  ago. 

The  State  must  help  the  hospitals.  The  work 
done  for  them  by  surgeons  and  physicians  must  be 
moderately  but  decently  paid  for  by  the  State,  whom 
they  serve;  and  by  such  patients  as  have  the  means. 
In  other  words,  the  hospitals  must  be  brought  into 
the  great  schemes  of  national  medical  insurance  which 
will  soon  be  part  of  the  structure  of  all  civilised 
States.     It  is  time  to  put  an  end  alike  to  the  much- 


356  SURGERY  AND  SOCIETY 

resented  "  abuse  "  of  the  hospitals  by  patients  who, 
whilst  not  "  poor,"  are  yet  unable  to  afford  the  sur- 
geon's fees,  and  to  the  other  economic  abuses,  includ- 
ing the  overcharging  of  the  well-to-do,  which  have 
grown  out  of  our  hospital  system. 

The  great  voluntary  hospitals  are  the  pride  of  our 
civilisation,  and  their  independence  is  their  dearest 
boast.  Under  it  they  have  attained  a  measure  of 
efficiency  in  the  treatment  of  disease  which  is  ex- 
celled nowhere ;  and  we  should  do  ill  to  deprive  them 
of  it.  They  are  rightly  jealous  of  their  liberty,  and 
I,  for  one,  should  be  sorry  to  interfere  in  any  way 
with  the  flow  of  benevolence  upon  which  that  lib- 
erty depends.  But  this  does  not  mean  that  the  hos- 
pital system  is  perfect,  or  that  it  is  incapable  of  im- 
provement save  at  the  cost  of  its  characteristic  fea- 
tures. 

The  reasons  why  we  must  deny  perfection  to  the 
hospital  system  have  in  large  measure  been  alluded 
to  already.  But  the  most  serious  reasons  are  yet  to 
come.  In  the  first  place,  the  institution  of  out-pa- 
tients is  not  only  abused,  but  is  in  itself  an  outrage 
upon  the  ideas  of  modern  scientific  medicine.  The 
herding  together  of  patients,  including  children,  in 
a  foul  atmosphere  full  of  infection,  for  hours  at  a 
time,  is  simply  disgusting  to  the  modern  hygienist. 
Yet  probably  every  medical  reader  of  these  pages 
can  recall  his  experience  of  some  great  hospital 
where,  so  far  as  the  in-patients  were  concerned,  the 
arrangements,  the  service  and  the  results  were  on 
the  way  to  perfection,  whilst  the  out-patient  depart- 
ment belonged  to  the  Dark  Ages. 


THE  PROVISION  OF  LISTERISM         357 

Undoubtedly  many  infections,  and  above  all  that 
of  tuberculosis,  must  thus  be  spread  by  the  hospitals. 
Whilst  curing  disease  they  thus  serve  most  unfortu- 
nately to  cause  it :  and  this  prepares  us  for  the  great 
indictment  of  the  modern  mind  against  these  mag- 
nificent institutions,  which  to  the  nineteenth  century 
seemed  the  last  word  in  human  provision  and 
achievement  regarding  disease.  The  hospitals  do 
nothing  to  prevent  disease.  As  I  have  shown,  they 
even  spread  it:  but  the  indictment  is  grave  enough 
that,  in  these  days  when  causation  is  studied  on  all 
hands,  and  prevention  is  the  key-word  of  the  future, 
the  hospitals,  with  their  superb  opportunities  in  the 
matter  of  money  and  skill  and  prestige,  do  nothing 
to  prevent  disease. 

My  business  in  this  chapter  is  simply  to  discuss 
the  provision  of  Listerism,  and  I  must  not  unduly 
anticipate  a  greater  question  still.  But  it  is  relevant 
to  our  present  discussion  to  show  that,  whilst  the  pro- 
vision of  Listerism  by  the  hospitals  is  admirable  so 
far  as  it  goes,  it  lacks  the  great  qualification  of  all 
medical  and  surgical  provision  of  the  future,  that  it 
must  be  at  once  curative  and  preventive. 

One  thing  only,  but  that  effectively  and  finally,  can 
put  the  hospitals  into  their  right  place  in  the  hygienic 
and  therapeutic  provision  of  the  future  State.  In- 
stead of  being  the  enemy  of  the  private  practitioner 
outside,  the  hospital  must  be  his  friend.  At  present 
we  see  these  two  great  institutions,  the  hospital  and 
the  private  practitioner,  who  should  be  in  exquisite 
co-ordination  and  co-operation  for  their  mutual  and 
for  the  common  good,  working  at  cross-purposes, 


358  SURGERY  AND  SOCIETY 

as  far  as  possible  independently,  but  with  mutual 
injury.  The  hospital  doctor,  working  for  nothing, 
not  because  he  is  more  charitable  but  because  he 
is  more  successful  and  makes  his  money  out  of  the 
system  indirectly,  is  the  enemy  of  the  outside  doc- 
tor, who  lives  by  the  patients  whom  he  can  keep. 
Could  anything  more  stupid  and  vicious  be  imag- 
ined? These  "  professional  brethren "  are  so 
placed  that,  at  every  point,  they  hamper  and  inter- 
fere with  each  other's  work,  to  the  inevitable  in- 
jury not  of  themselves  only,  but  of  the  community 
at  large.  The  outside  doctor  loses  money  whenever 
his  patient,  not  being  a  contract  patient,  enters  the 
hospital.  It  is  not  to  his  interest  to  send  his  pa- 
tients at  the  earliest  moment,  say  when  a  doubtful 
cancer  is  present,  and  thus  the  utility  of  the  hospital 
surgeon  is  often  frustrated.  Neither  the  hospital 
doctor  nor  the  outside  doctor  is  in  the  least  con- 
cerned to  advise  the  man  who  smokes  until  he  hurts 
his  tongue,  or  allows  a  jagged  tooth  to  irritate  it, 
that  he  must  remove  the  cause  of  irritation,  or  can- 
cer will  very  likely  be  the  result.  The  hospital  sur- 
geon can  open  a  tuberculous  abscess  in  a  clean  fash- 
ion, and  the  hospital  nurses  can  keep  it  clean:  but 
the  outside  doctor  must  live,  and  he  opens  the  ab- 
scess himself,  so  that  the  hospital  surgeon  does  not 
see  it  until  there  is  a  mixture  of  microbes  present, 
confronted  with  which  his  knife  is  impotent  to  save, 
and  his  superb  aseptic  technique  a  mockery.  And 
it  is  the  business  neither  of  the  hospital  surgeon, 
nor  of  the  outside  practitioner,  to  teach  parents  that 
they  must  not  give  unboiled  milk  to  young  children 


THE  PROVISION  OF  LISTERISM         359 

until  vested  interests  and  apathy  and  ignorance  are 
permitted  no  longer  to  poison  us  with  the  milk  of 
tuberculous  cows  wherever  milk  is  drunk  at  all. 

Evidently  if  we  are  to  achieve  what  we  shall 
achieve,  and  send  tuberculosis  to  keep  company  with 
typhus  and  leprosy,  we  require  a  fundamental  altera- 
tion in  the  system  which  daily  produces  such  deplora- 
ble results.  Not  only  do  we  require  it,  but  so  far 
as  Great  Britain  is  concerned  we  are  about  to  obtain 
it.  The  system  of  national  insurance  which  will  be 
set  to  work  a  few  months  after  the  publication  of 
these  pages,  will  necessarily  mark  an  epoch  in  the 
provision  of  Listerism,  to  mention  nothing  else,  by 
the  most  radical  imaginable  alteration  of  the  condi- 
tions of  medical  practice  in  this  country. 

As  I  repeatedly  pointed  out  in  my  attempts  to  aid 
the  passage  and  acceptance  of  the  bill,  it  establishes 
the  only  rational  condition  of  medical  and  surgical 
practice  in  the  twentieth  century,  in  that  it  pays  the 
doctor  for  health  and  not  for  disease.  Hitherto,  the 
doctor  has  profited  by  illness,  and  where  there  is 
health  he  starves.  But  under  a  fair  system  of  con- 
tract practice,  it  pays  the  doctor  to  maintain  the 
health  of  his  patients  and  of  the  community  at  the 
highest  possible  standard.  In  his  own  professional 
interest  he  is  bound  to  become  a  teacher  of  hygiene, 
a  temperance  reformer,  and  even  a  Eugenist.  If, 
however,  his  instructions  have  failed,  and  he  is  con- 
fronted with,  say,  a  case  of  "  surgical  tuberculosis," 
which  wise  precautions  about  milk  would  have 
averted,  the  practitioner  will  be  no  longer  tempted 
to  undertake  the  task  of  opening  an  abscess  which 


360  SURGERY  AND  SOCIETY 

will  thereafter  never  close,  since  its  secondary  infec- 
tion is  certain.  The  hospitals,  which  have  so  long 
robbed  the  general  practitioner,  now  become  a  god- 
send to  him.  Why  on  earth  should  he  face  the 
trouble,  the  labour,  the  risk,  the  prolonged  and  hope- 
less post-operative  course  of  a  tuberculous  abscess, 
when  the  hospital  is  available  to  relieve  him  of  the 
case,  to  deal  with  it  under  the  best  conditions,  and 
yet  not  rob  him  of  a  single  fee?  Plainly,  so  far  as 
this  sort  of  thing  is  concerned,  the  bad  old  days  are 
practically  over.  The  surgeon  inside  the  hospital 
and  the  general  practitioner  outside  it  must  forth- 
with become  professional  brethren  indeed,  working 
into  each  other's  hands  at  every  point.  It  is  no 
longer  to  the  interest  of  the  practitioner  to  watch 
doubtful  cases  of  cancer  until  they  become  certain 
—  and  hopeless.  It  is  no  longer  to  his  interest  to 
treat  a  single  case,  indeed,  which  the  hospitals  will 
accept.  It  is  plain  that  any  friction  which  may 
hereafter  arise  between  the  hospitals  and  the  outside 
doctors  will  be  very  different  from  that  of  the  past, 
and  the  hospitals  may  have  to  protect  themselves. 
But  at  any  rate  their  surgeons  will  get  their  cases 
much  earlier  than  ever  before,  and  will  also  get 
many  cases,  suitable  only  for  hospital  treatment, 
which  they  would  not  otherwise  have  seen  at  all. 
The  gain  to  the  hospital  surgeons  will  be  enormous 
so  far  as  their  results,  and  therefore  their  satisfac- 
tion in  their  work,  are  concerned.  A  vastly  in- 
creased number  of  patients  will  pass  through  the 
hospitals,  whilst  the  average  number  of  days  spent 
in  hospitals  by  the  patients  will  be  greatly  dimin- 


THE  PROVISION  OF  LISTERISM         361 

ished  owing  to  the  surgical  advantages  of  earlier 
treatment,  and  of  treatment  which  is  not  complicated 
by  disastrous  attempts  already  made  outside. 

The  work  of  the  hospitals  will  be  greatly  light- 
ened so  far  as  the  out-patient  departments  are  con- 
cerned. There  should  be  no  such  places.  Outside 
doctors  ought  to  be  able  to  deal  adequately  with 
this  class  of  case,  and  under  a  general  system  of  in- 
surance the  patients  will  be  able  to  consult  them. 
I  am  well  aware  that  initial  proposals  can  deal  only 
with  certain  classes  of  patients,  but  I  am  now  dis- 
cussing the  principle  in  general,  well  knowing  that 
it  will  be  applied,  before  very  long,  to  women  and 
children  also,  in  this  and  all  other  progressive  coun- 
tries. The  money  and  space  thus  saved  in  our  out- 
patient departments  will  be  made  available  for  the 
obvious  and  proper  function  of  a  hospital  —  to  treat 
patients  who  cannot  be  properly  treated  otherwise 
than  in  a  hospital.  The  out-patient  department  will 
be  retained  for  accidents,  and  for  all  manner  of 
specialities,  such  as  the  treatment  of  the  eyes  and 
ears,  in  which  the  general  practitioner  cannot  possi- 
bly attain  sufficient  expertness;  but  the  general  out- 
patient departments  will  disappear,  to  the  great  ad- 
vantage of  everyone  concerned. 

Not  only  the  surgical  wards  but  the  medical  wards 
also  of  the  hospitals  will  soon  discover  that,  under 
a  system  of  national  insurance,  the  pressure  upon 
their  space  greatly  rises.  They  offer  advantages 
which  are  paralleled  only  in  the  nursing  homes  pro- 
vided for  the  wealthy;  the  prejudice  against  them 
is  steadily  breaking  down;   and  the  entry  of   (in- 


36a  SURGERY  AND  SOCIETY 

sured)  patients  into  them  no  longer  robs  the  doc- 
tor, but  saves  him  time  and  money  and  responsi- 
bility. These  considerations  are  perfectly  evident, 
but  they  have  hitherto  been  taken  very  little  into 
account.  Our  new  system  of  insurance  in  this  coun- 
try has  been  discussed  from  the  point  of  view  of 
many  special  interests;  but  too  little  from  the  point 
of  view  of  the  public  welfare  at  large.  The  hos- 
pitals have  been  completely  left  out  of  the  scheme; 
a  sufficiently  extraordinary  circumstance  when  one 
considers  the  part  they  play  in  the  treatment  of  dis- 
ease, and  their  increasing  importance  under  recent 
developments  of  medical  and  surgical  method.  It  is, 
I  believe,  correct  to  say  that  only  one  question  has 
been  discussed  —  and  that,  from  the  national  and 
hygienic  point  of  view,  the  least  important  of  all. 
It  has  been  feared  and  argued  that  the  subscriptions 
to  the  hospitals  will  fall  off.  Very  probably  they 
will,  and  perhaps  they  will  not :  but  what  a  question 
to  trouble  about  when  we  are  creating  a  great  na- 
tional system  of  dealing  with  disease!  Our  real 
business,  of  course,  is  to  ask  where  the  hospitals 
should  come  into  the  system,  and  how  they  can  be 
made  most  serviceable,  recognising  their  unique  and 
indispensable  position  in  relation  to  the  whole  prob- 
lem. Instead  of  this,  we  have  invented  a  huge  sys- 
tem which  ignores  the  hospitals  altogether,  and  we 
take  notice  of  their  existence  only  to  speculate 
whether  they  will  "  suffer  "  by  the  reduction  of  the 
subscriptions  of  the  charitable. 

But,  indeed,  we  are  establishing  conditions  so  ex- 
tensive and  so  novel  that  the  hospitals  will  be  greatly 


THE  PROVISION  OF  LISTERISM         363 

affected,  whether  or  not  we  suppose  ourselves  to 
be  leaving  them  out  altogether,  whether  or  not  their 
subscriptions  rise  or  fall.  All  I  have  already  shown, 
not  only  do  we  go  far  towards  abolishing  the  gen- 
eral out-patient  departments,  but  we  are  going  to 
increase  enormously  the  demands  for  admission  to 
the  wards,  and  we  are  actually  reversing  the  eco- 
nomical relation  —  at  present  simply  insane  —  be- 
tween the  doctor  inside  and  the  doctor  outside  the 
hospital.  Very  plainly,  therefore,  the  hospitals  are 
coming  into  our  scheme,  whether  we  realise  it  or  not. 
The  system  of  the  future,  towards  which  the  present 
national  insurance  is,  of  course,  a  mere  step,  will 
certainly  not  leave  out  the  hospitals:  but  the  pres- 
ent scheme  is  quite  sufficient  to  involve  the  hospitals 
very  closely. 

There  has  always  been  talk  of  paying  sums  to  the 
hospitals  on  account  of  insured  patients  whom  they 
treat :  and  this  marks  the  beginning  of  the  end  of  their 
present  economic  basis.  The  hospitals  glory  in  their 
voluntary  character  —  even  though  they  be  com- 
pelled to  close  whole  wards  for  months  at  a  time  — 
and  those  who  serve  them  greatly  resent  the  notion 
of  State  supervision.  These  ideas  are  out  of  place 
in  the  present  century,  and  they  must  certainly  be 
abandoned.  Whatever  their  economic  basis,  hos- 
pitals are  institutions  of  society,  performing  great 
and  necessary  social  functions,  and  the  only  business 
of  the  real  politician  is  to  do  whatever  may  be  re- 
quired to  aid  them  in  performing  those  functions 
better  than  ever.  Something  is  wrong  when  hos- 
pitals have  to  close  wards  for  lack  of  funds,  whilst 


364  SURGERY  AND  SOCIETY 

patients  are  suffering  outside,  and  the  nation's  effi- 
ciency is  weakened  in  proportion.  Something  is 
wrong  when  surgeons  in  the  hospitals,  working  un- 
der the  most  admirable  conditions  in  all  other  re- 
spects, and  unsurpassed  in  their  skill,  are  doomed 
to  a  large  measure  of  failure  because  they  do  not 
get  their  patients  in  time.  Something  is  wrong 
when,  in  this  twentieth  century  of  science,  and  the 
recognition  of  causes,  these  magnificent  institutions 
are  confined  to  the  function  of  curing  disease  — 
which  is  more  commonly  not  cure  but  only  relief  or 
palliation  —  and  do  nothing  to  prevent  it. 

These  anomalies  and  archaisms  are  already 
doomed  in  this  country  by  our  system  of  national 
insurance.  Yearly  the  State  becomes  more  organ- 
ised and  organic.  As  Mr.  Ramsay  Macdonald  has 
justly  observed,  the  old  nineteenth  century  antithe- 
sis, "  the  Man  versus  the  State,"  which  meant  so 
much  to  Herbert  Spencer  and  his  contemporaries,  is 
becoming  an  absurdity.  The  hospitals  cannot  pos- 
sibly stand  outside  the  structure  of  the  highly  organ- 
ised State  of  the  immediate  future. 

In  taking  their  due  place  as  organs  of  the  State, 
the  hospitals  need  lose,  and  will  lose,  nothing  what- 
ever of  their  present  dignity.  If  they  accept  money 
from  the  State  on  account  of  insured  persons,  as 
they  will  certainly  have  to  do,  doubtless  they  will 
have  to  submit  to  some  measure  of  State  inspection. 
But  why  not?  They  have  nothing  whatever  to 
fear;  why  should  they  behave  as  if  they  thought 
they  had?  All  manner  of  institutions  are  now  in- 
spected, and  even  private  individuals  such  as  physi- 


THE  PROVISION  OF  LISTERISM         365 

ologists  holding  certificates  for  experiments  upon 
animals.  These  lose  no  dignity  by  the  process,  nor 
need  the  hospitals.  The  inspectors  would  naturally 
be  elderly  physicians  and  surgeons  of  the  highest 
standing,  such  as  now  watch  over  the  interests  of  the 
insane ;  and  their  work  would  simply  involve  helping 
the  hospitals  by  their  experience  and  advice.  The 
prejudice  against  the  hospitals  which  exists  in  many 
minds,  and  which  is  nourished  by  the  unscrupulous 
inventions  of  some  of  the  anti-vivisectionists,  would 
be  all  the  more  rapidly  dissipated  if  it  were  known 
that  they  were  inspected  as  lunatic  asylums  most 
rightly  are  inspected  already.  Whosoever  please 
may  maintain  voluntary  hospitals  hereafter  as  here- 
tofore, whether  on  account  of  special  modes  of  treat- 
ment, or  to  satisfy  the  individualism  of  their  temper- 
ament; and  such  institutions  will  serve  many  valu- 
able purposes.  But  the  great  existing  hospitals, 
which  spend  such  huge  sums  of  money,  and  which 
perform  the  great  national  function  of  training  fu- 
ture practitioners  —  these  will  be  required,  in  the 
future,  to  do  their  work  far  better  than  in  the  past, 
or  at  present,  even  granting  that  their  services  are 
already  incalculable  in  value,  and  by  no  means  to  be 
replaced. 

The  fear  that  subscriptions  to  the  hospitals  will 
fall  off  is  entirely  justified,  and  quotation  of  the  sup- 
posed experience  of  Germany  to  the  contrary  may 
be  ignored.  Work-people  who  have  hitherto  reg- 
ularly subscribed  small  sums,  by  no  means  to  be  de- 
spised in  the  aggregate,  will  cease  to  do  so,  now  that 
they  are  to  pay  a  weekly  tax  for  the  same  purpose. 


366  SURGERY  AND  SOCIETY. 

Employers  are  already  making  new  arrangements  in 
this  respect,  nor  can  they  very  well  be  blamed. 
Many  of  them,  in  the  first  place,  having  no  charity 
in  their  souls,  have  subscribed  to  the  hospitals  for 
appearance'  sake,  and  in  order  to  have  a  claim 
upon  them  for  their  employees.  Many  have  thus 
saved  themselves,  many  times  over,  the  cost  of  their 
"  charitable  "  subscription.  These,  of  course,  will 
now  cease  to  subscribe.  But  others  will  be  no  less 
justified  in  doing  so.  In  many  cases  the  annual  con- 
tributions, by  way  of  insurance,  will  amount  to  thou- 
sands of  pounds,  and  there  is  no  reason  or  justice  in 
expecting  them  to  subscribe  any  more. 

The  resources  of  the  hospitals  will  therefore  un- 
dergo a  rapid  and  enormous  shrinkage  just  at  the 
very  time  when  the  demand  upon  them  will  be 
greatly  multiplied.  This  demand  will  mainly  be 
made  by  patients  who  are  insured,  and  it  is  quite 
evident  that  the  hospitals  will  have  no  choice  but  to 
deal  with  these  patients  and  be  paid  for  them. 

In  ten  years  the  hospitals  will  be  what  they  should 
be,  and  what  they  must  necessarily  become,  whether 
they  should  or  not.  They  will  be  great  organs  of 
the  State,  supported  by  the  State,  served  by  a  su- 
perior and  specialised  race  of  competent  and  prop- 
erly remunerated  doctors.  There  will  be  many  to 
declare  that  this  is  "  the  end  of  all  things  " —  as  the 
backboneless  said  of  the  first  vertebrates,  the  reptiles 
of  the  first  birds,  and  so  forth  —  but  such  voices  will 
not  belong  to  those  who  know  the  present  facts  and 
do  not  personally  profit  by  them,  as  most  of  the  so- 
called  leaders  of  the  profession  do  to-day. 


THE  PROVISION  OF  LISTERISM         367 

The  provision  of  Listerism  will  then  be  made 
perfectly  adequate  to  the  need  —  which  itself  will 
undergo  profound  and  rapid  changes,  as  we  shall 
see  in  the  concluding  chapter  of  this  study.  If  more 
beds  are  required  than  already  exist,  they  will  have 
to  be  provided.  Many  of  us  hold  that  the  name  and 
dignity  of  charity  are  poorly  served  by  the  present 
spectacle  of  the  hospitals,  forever  begging  the  con- 
tributions of  the  charitable,  declaring  that  "  funds 
are  urgently  needed,"  often  closing  wards  for  econ- 
omy's sake,  competing  with  one  another  for  public 
support  by  every  manner  of  advertisement,  and 
withal  lending  no  hand  whatever  in  the  prevention 
of  disease.  Real  charity  is  of  a  different  order. 
The  community  has  a  duty  to  the  ill,  and  its  duty  to 
them  is  also  its  duty  to  itself,  on  the  grounds  alike 
of  national  efficiency  and  national  economy.  When 
we  come  to  look  at  disease  sociologically,  we  dis- 
cover that  by  far  the  cheapest  way  of  dealing  with  ill 
persons,  consumptives  or  whatever  else  they  be,  is 
to  cure  them,  if  possible.  Failing  cure,  they  become 
a  burden  upon  the  community  in  workhouse  and 
prison  and  asylum.  The  provision  of  the  best  med- 
ical and  surgical  treatment  for  ill  persons  is  there- 
fore a  necessary  duty  of  the  State,  second  only  to  its 
duty  of  preventing  illness  altogether. 

In  the  course  of  making  these  great  changes,  and 
placing  the  hospitals  in  their  due  place  in  the  future 
State,  the  public  will  be  compelled  to  listen  to  many 
dissonant  voices.  Let  us  beware.  The  man  who 
has  succeeded  in  establishing  himself  in  a  favourable 
relation  to  the  present  system,  and  who  is  also  com- 


368  SURGERY  AND  SOCIETY 

monly  a  conspicuous  representative  of  the  profes- 
sion, cannot  be  looked  upon  as  probably  an  impartial 
witness.  It  may  be  replied  that,  if  the  public  is  not 
to  trust  the  leading  consultants  in  such  a  matter, 
whom  can  it  trust?  To  this  the  reply  is  that  the 
medical  profession,  in  these  latter  days,  begins  to 
include  amongst  its  members  not  a  few  who  are  su- 
premely entitled  to  be  heard,  and  who  speak  without 
prejudice.  The  man  to  listen  to  is  not  he  who 
makes  huge  fees  out  of  his  hospital  connexion,  for 
which  he  has  waited  and  expended  money  and  la- 
bour for  years  in  the  past :  but  the  leading  members 
of  our  Preventive  Medical  Service,  who  alone  are 
capable,  by  their  experience  and  their  relation  to  the 
problem,  of  looking  at  it  from  the  only  possible 
standpoint  for  our  times,  which  is  that  of  preven- 
tion. These  great  authorities  are  almost  all  in 
official  posts,  and  are  forbidden  to  direct  the  public. 
The  more's  the  pity,  for  there  would  be  no  reply  to 
their  arguments.  Professor  Benjamin  Moore  has 
done  great  service,  in  his  "  Dawn  of  the  Health 
Age,"  in  discussing  these  questions  candidly  and  with 
authority,  and  it  is  earnestly  to  be  desired  that  the  in- 
telligent public  should  acquaint  itself  with  that  book 
and  with  "  The  State  and  the  Doctor,"  and  "  The 
Prevention  of  Destitution,"  by  Mr.  and  Mrs.  Sidney 
Webb,  of  whom  I  lately  heard  it  said  by  the  chief 
official  of  hygiene  in  these  islands  that  they  had  done 
more  for  dealing  with  the  problem  of  disease  than 
anyone  else  now  living.  Those  who  look  upon 
these  matters  from  the  standpoint  of  the  practitioner 


THE  PROVISION  OF  LISTERISM         369 

essay  no  reply  to  such  books  as  these,  for  the  excel- 
lent reason  that  they  cannot. 

This  great  and  beneficent  change  is  much  nearer 
at  hand  than  most  of  us  realise,  for  the  majority  of 
the  medical  profession  will  soon  be  in  favour  of  it. 
The  life  of  the  general  practitioner  has  been  be- 
coming steadily  more  difficult  for  many  years  past. 
He  is  doomed  practically  to  disappear,  but  for  a 
few  more  years  the  Insurance  Bill,  which  confers 
so  many  boons  upon  him,  will  give  him  a  new  lease 
of  life.  His  first  discovery  will  be  that  the  hos- 
pitals, hitherto  his  enemies,  are  now  his  friends. 
The  more  he  can  avail  himself  of  them,  the  better 
paid  and  the  lighter  will  become  his  work.  At  first 
the  hospitals  will  simply  have  to  turn  away  a  multi- 
tude of  their  new  would-be  patients.  Later,  ac- 
commodation will  have  to  be  provided  for  them, 
under  the  new  economic  conditions,  and  the  change 
will  equally  suit  the  general  practitioner  and  the 
new  entrants  into  the  medical  profession,  who  will 
find  gradually  opening  to  them  a  far  larger  number 
than  ever  heretofore  of  those  properly  paid  posts 
which  are  already  beginning  to  withdraw  from 
private  practice  a  very  large  proportion  of  the  best 
young  brains  of  the  profession. 

All  this  will  be  to  the  good,  deplore  it  who  may. 
The  monopolists  may  suffer,  but  they  have  had  their 
day.  The  truth  is  that  the  advance  of  science  has 
rendered  general  practice  under  the  old  conditions 
simply  impossible.  All  over  the  country,  no  doubt, 
and  especially  in  the  rural  districts,  it  is  still  main- 


370  SURGERY  AND  SOCIETY 

tained,  but  it  is  not  modern  medicine,  nor  anything 
like  it.  There  are  still  men  who  wash  their  empty 
bottles  into  a  large  receptacle  labelled  A.D.S.,  and 
use  the  contents  for  their  poorer  patients  —  the 
mystic  letters  simply  meaning  Any  Damned  Stuff. 
But  their  hour  has  struck. 

Consider  the  problem  of  the  honest  general  prac- 
titioner who  is  faced  with  any  one  of  a  hundred  types 
of  case  which,  in  the  past,  were  simply  treated  with 
drugs  which  cloaked  the  symptoms.  Diagnosis  is 
no  longer  made  merely  by  listening  to  the  chest, 
feeling  the  pulse,  taking  the  temperature  and  so 
forth.  It  involves  all  these  as  preliminaries,  and 
then  much  more.  This  much  more  takes  a  very 
long  time,  a  variety  of  expensive  apparatus,  and 
much  expert  skill.  The  blood  must  be  examined  in 
half  a  dozen  ways.  The  "  opsonic  index,"  perhaps, 
must  be  estimated.  The  bacteriology  of  the  case 
must  be  investigated,  and  inoculations  may  have  to 
be  made  into  living  animals.  Finally,  it  is  quite 
likely  that  some  kind  of  serum  or  vaccine  will  have 
to  be  prepared  from  the  bacteria  which  have  been 
obtained  from  the  patient. 

These  are  not  exceptional  cases.  They  are  every- 
day necessities  in  the  modern  hospital,  and  daily 
call  for 'the  services  of  half  a  dozen  experts,  and 
hundreds  or  thousands  of  pounds  worth  of  labora- 
tories and  apparatus.  In  such  hospitals  these  things 
are  at  the  service  of  the  poorest  patient.  How  on 
earth  can  the  general  practitioner  maintain  this  kind 
of  standard,  or  anything  remotely  approaching  it, 
for  his  private  patients?     Even  if  he  had  the  knowl- 


THE  PROVISION  OF  LISTERISM         371 

edge  and  the  skill,  which  no  one  man  has,  even  if 
he  possessed  the  laboratories  and  the  apparatus, 
somewhere  in  the  wilds  of  Sussex  or  Argyllshire,  he 
has  not  the  time.  The  problem  is  many  times  over 
insoluble,  by  the  nature  of  the  case,  but  we  have  no 
sooner  said  so,  and  admitted  that  these  are  the  de- 
mands which  modern  science  makes  on  behalf  of  the 
invalid,  than  we  have  admitted  that  the  greater  part 
of  general  practice  must  disappear. 

Recently,  in  a  remote  corner  of  Scotland,  I  met 
a  general  practitioner  of  the  very  best  type,  who 
had  been  a  fellow-student  of  my  own,  and  who  had 
acquired  particular  skill  in  the  examination  of  the 
blood  and  in  surgery.  "  I  have  not  done  a  blood 
for  seven  years,"  he  told  me,  meaning  thereby  that 
he  had  not  made  a  single  examination  of  the  kind 
which,  ten  years  before,  he  had  made  many  times 
over  daily  in  hospital.  When  I  asked  him  about 
the  Insurance  Bill,  he  said  it  did  not  affect  him  per- 
sonally, "  But  of  course  we  are  all  fighting  it,  shoul- 
der to  shoulder."  Like  tens  of  thousands  of  other 
practitioners,  he  had  not  read  the  Bill,  and  was  com- 
pletely misled  by  those  who  have  done  the  profes- 
sion so  little  honour  in  this  matter.  He  knew  very 
well  that  the  general  practice,  as  he  was  compelled 
to  carry  it  on,  to  the  best  of  his  no  small  ability, 
and  working  very  hard  indeed,  is  a  farce  and  an 
anachronism,  and  cannot  possibly  be  anything  else. 
He  knew  that  half  the  training  of  his  student  years, 
and  all  his  skill  in  hematology  and  surgery  (which 
he  had  entirely  given  up,  sending  his  cases  to  Edin- 
burgh) were  completely  wasted,  but  he  saw  no  way 


372  SURGERY  AND  SOCIETY 

out.  The  revolution  of  1911-1912  provides  that 
way  out;  and  men  like  my  friend,  in  the  future,  will 
do  the  work  for  which  they  have  fitted  themselves 
under  proper  conditions. 

The  solution  of  the  present  problem  of  the  mid- 
dle-classes is  also  not  far  distant:  but  it  depends 
upon  popular  education  in  these  matters.  Surgical 
fees,  as  I  have  already  shown,  are  at  present  out- 
rageously high  —  compared,  for  instance,  with  those 
paid  to  physicians  of  corresponding  rank.  Patients 
in  London  are  charged  two  and  three  guineas  for 
simple  examinations  which  would  be  just  as  well 
performed  in  Paris  for  fifteen  francs.  The  use  of 
private  nursing-homes  too  often  degenerates  into 
gross  abuse,  as  when  a  patient  in  excellent  health, 
who  is  about  to  undergo  a  simple  operation,  say  for 
haemorrhoids,  is  kept  for  three  weeks  before  the 
operation,  instead  of  one  day  or  half-day,  in  a  nurs- 
ing-home where  he  is  charged  eight  guineas  a  week, 
as  a  preliminary  to  paying  a  fee  of  fifty  guineas  to 
the  surgeon.  All  this  is  going,  though  powerful 
vested  interests  are  at  work  to  prevent  reform,  as 
some  recent  cases  testify. 

There  is,  of  course,  no  reason  in  the  world  why, 
in  the  near  future,  there  should  not  be  beds  avail- 
able in  the  great  hospitals  —  as  there  now  are,  for 
instance,  at  St.  Thomas's  —  where  patients  can  be 
treated  and  operated  upon  by  their  own  doctor,  or 
by  one  of  the  hospital  doctors,  at  reasonable  sums. 
This  much  needed  reform  will  follow  upon  that 
breaking-down   of  the   hospital   surgeon's  preserve 


THE  PROVISION  OF  LISTERISxM         373 

which  will  follow  from  the  establishment  of  national 
insurance. 

Most  important  of  all,  from  the  national  point 
of  view,  is  the  provision  of  Listerism  for  children. 
Medical  inspection  of  school  children  is  now  reveal- 
ing their  need  in  Great  Britain  —  a  need  which,  one 
need  scarcely  say,  can  be  readily  paralleled  in  other 
parts  of  the  world.  Medical  inspection  having 
come,  treatment  must  inevitably  follow.  In  Great 
Britain  in  this  year  191 1  we  have  six  million  school 
children,  subject  to  inspection,  and  at  present  under 
the  care  of  about  a  thousand  school  medical  officers. 
(The  figure  is  small  enough,  but  it  illustrates  my 
point  that  the  proportion  of  practitioners  no  longer 
engaged  in  private  practice  is  rapidly  rising,  and  will 
ere  long  alter  the  whole  balance  of  feeling  in  the 
profession.)  Of  these  children  there  are  scores  of 
thousands  who  require  treatment  for  surgical  tuber- 
culosis alone.  Some  8  per  cent,  at  least  require  the 
services  of  nasal  surgery  for  adenoids,  enlarged 
tonsils,  etc. ;  and  the  greater  number  are  in  immedi- 
ate need  of  dental  surgery. 

Provision  of  all  this  need  must  forthwith  be  made 
—  and  none  the  less  because  the  State  is  now  under- 
taking to  pay  for  disease  and  its  consequences  in 
later  years.  The  Insurance  Bill  begins  nowhere 
near  the  beginning.     What  is  to  be  done? 

There  can  be  no  question  —  there  never  has  been 
any  question  —  as  to  the  answer.  The  school  au- 
thorities have  sometimes  tried  to  make  arrangements 
for  the  treatment  of  these  needy  children  by  local 


374  SURGERY  AND  SOCIETY 

practitioners.  The  fatal  objection  to  this  is  that, 
taken  as  a  whole,  the  local  practitioners  are  hope- 
lessly incompetent.  Elsewhere  the  idea  has  been 
for  the  Education  Authority  to  make  arrangements 
for  the  treatment  of  its  children  in  the  out-patient 
departments  of  hospitals.  This  palpably  mad  and 
wasteful  and  cruel  method  has,  for  some  time  past, 
been  adopted  by  the  London  County  Council,  at  the 
instance  of  entirely  unqualified  and  incompetent  ad- 
visers. Here  in  London  the  consequences  have 
been  horrible,  a  continuous  scandal  of  the  first  or- 
der, to  which  the  Board  of  Education  has  repeatedly 
drawn  attention  in  the  severest  terms.  The  Coun- 
cil and  the  Board  are  on  opposite  sides  in  politics, 
and  the  lives  and  eyes  and  ears  and  teeth  of  Lon- 
don's children  have  been  sacrificed  wholesale  in 
consequence. 

The  only  possible  method  is  the  School  Clinic, 
long  and  triumphantly  established  in  Germany, 
staffed  by  competent,  modern  practitioners  who 
should,  for  choice,  devote  their  whole  time  to  this 
splendid  work.  Experts  of  various  kinds  will  also 
be  required  to  spend  more  or  less  of  their  time  deal- 
ing with  eyes  and  ears  and  noses  and  teeth.  Every 
school  must  be  connected  with  a  school  clinic,  en- 
tirely its  own,  or  shared  with  others,  according  to 
circumstances.  Parents  must  be  called  into  the 
business,  and  summarily  prosecuted,  if  necessary, 
when  they  wilfully  fail  to  carry  out  instructions. 
All  this  is,  no  doubt,  a  very  bad  look-out  for  the  in- 
competent general  practitioner,  but  we  must  give  up 
drugging  for  real  doctoring  in  these  days;  and  no 


THE  PROVISION  OF  LISTERISM         375 

State  can  afford  to  countenance  any  longer  the  type 
of  man  to  whose  mercies  these  children  have  com- 
monly been  left  hitherto.  All  this  scheme  will  take 
its  natural  and  necessary  part  in  the  structure  of  the 
National  Health  Service  of  the  near  future. 

In  rural  districts  attempts  are  still  being  made, 
with  hopeless  consequences  on  the  whole,  to  utilise 
the  local  practitioners.  The  only  alternative  is  a 
travelling  clinic  for  such  districts,  and  to  this  we 
shall  shortly  come. 

But  it  is  the  considerations  advanced  in  the  next 
chapter  that  will  really  determine  future  progress. 


CHAPTER  XVII 

THE  PROMISE  OF  THE  FUTURE 

To  the  distant  historian  the  record  of  Listerism  will 
appear  curious  indeed.  Here  is  the  most  beneficent 
achievement  of  the  human  mind,  coming  to  its  ma- 
turity within  a  generation,  when  all  preceding  gen- 
erations have  gone  without  it,  and  then  suddenly 
undergoing  the  most  extraordinary  decline  in  its 
scope,  after  threatening  to  supersede  all  other  forms 
of  treatment.  This,  as  we  shall  see,  is  the  devel- 
opment now  at  hand. 

But,  hitherto,  in  its  brief  and  brilliant  career, 
Listerism  has  advanced  from  one  part  of  the  body 
to  another,  and  from  one  type  of  malady  to  another, 
until  mere  medicine  threatened  to  disappear  alto- 
gether. The  surgeon  has  advanced  from  the  limbs 
to  the  trunk,  from  the  abdomen  to  the  cranium,  and 
from  the  cranium  even  to  the  heart,  until  it  seemed 
as  if  the  Listerian  knife  were  to  prove  to  be  the  long- 
sought  panacea.  The  next  stage  in  the  history  of 
its  achievement  will  depend  upon  the  fact  that  the 
very  discoveries  which  have  made  it  possible  are  now 
proceeding  to  supersede  it.  Let  us  consider  some 
instances,  and  let  these  considerations  find  a  place  of 
prominence  at  the  end  of  this  volume,  lest  the  com- 
mentator suppose  that  enthusiasm  for  Listerism  has 

376 


THE  PROMISE  OF  THE  FUTURE        377, 

blinded  the  writer  to  the  possibility  of  something  far 
better. 

Let  us  take  the  highly  representative  case  of  what 
is  usually  called  "  surgical  tuberculosis."  A  child 
has  a  "  white  swelling "  of  the  knee-joint,  which 
yields  to  no  remedies.  Later  he  suffers  from  start- 
ing-pains at  night,  and  serious  lameness.  After  in- 
jections of  iodoform  and  other  remedies  have  been 
tried,  Listerism  is  called  in.  The  surgeon  exposes 
the  knee-joint  and  removes  it  in  toto.  He  apposes 
the  thigh-bone  and  the  shin-bone,  each  with  a  per- 
fectly healthy  raw  surface,  the  disease  having  been 
completely  removed,  and  they  soon  unite,  giving  the 
patient  a  single  shaft  of  healthy  bone  from  hip 
to  ankle.  This  is  a  remarkable  and  triumphant 
achievement  for  Listerism,  utterly  unthinkable,  be- 
cause then  simply  murderous,  to  the  surgeons  of  lit- 
tle more  than  a  generation  ago.  All  honour  to  the 
observers  and  pioneers  and  followers  who  have 
given  relief  in  this  fashion  to  countless  victims  of 
tuberculosis  in  the  knee-joint. 

But  now  let  us  consider.  What  is  this  tubercu- 
losis in  the  knee-joint?  It  is  a  slow  inflammation. 
Now  Lister  long  ago  declared  and  demonstrated 
that  the  more  ordinary  and  acute  surgical  inflamma- 
tions are  due  to  microbes;  and  he  showed,  first,  the 
excellent  results  of  killing  the  microbes,  and  second, 
the  still  more  excellent  results  of  excluding  them. 
Some  fourteen  years  after  Lister's  beginning  —  in 
1 88 1,  to  be  precise  —  Professor  Robert  Koch 
showed  that  a  special  microbe,  called  the  tubercle 


378  SURGERY  AND  SOCIETY 

bacillus,  is  the  cause  of  tuberculosis  in  all  its  forms. 
Needless  to  say,  the  Listerian  idea  has  been  applied 
ever  since  to  this  and  all  other  cases  of  microbic  in- 
fection. Whether  or  not  the  surgeon  is  called  in, 
we  seek  to  kill  the  microbes  by  means  of  medicinal 
antiseptics,  just  after  the  fashion  of  Lister  applying 
carbolic  acid  to  a  compound  fracture. 

But  though  antiseptic  medicaments,  on  the  sur- 
gical principle,  are  now  given  in  all  manner  of  ways 
for  all  manner  of  diseases,  their  results  are  on  the 
whole  extremely  disappointing.  If  they  are  to 
reach  the  remote  microbes  through  the  blood-stream 
in  sufficient  concentration,  they  must  probably  first 
kill  the  patient. 

But  if  the  antiseptic  principle  will  not  avail,  what 
of  the  aseptic?  Why  should  we  not,  in  our  medical 
practice,  and  in  our  State  Medicine,  take  a  hint  from 
the  later  development  of  Listerism,  which  aims  at 
excluding  microbes  altogether? 

For  consider  now  the  case  of  "  surgical  tubercu- 
losis.*' Here  is  an  exceedingly  common  and  de- 
structive disease,  from  which  scores  of  thousands  of 
schoolchildren  are  suffering  in  Great  Britain  at  this 
moment.  It  attacks  the  glands  in  the  neck,  the 
spine  and  long  bones,  the  joints,  especially  the  knee- 
joint  and  hip-joint,  the  coverings  of  the  brain  and 
the  brain  itself,  the  lining  of  the  abdomen  and  the 
interior  of  the  bowels.  It  is  a  brutal,  chronic,  des- 
perately intractable  and  exceedingly  widespread 
disease  which,  in  one  form  or  other,  is  probably  re- 
sponsible for  about  twelve  to  fifteen  thousand  deaths 
annually  in  Great  Britain,  and  for  more  pain  and 


THE  PROMISE  OF  THE  FUTURE        379 

inefficiency  and  expense  than  words  or  figures  can 
estimate. 

Here,  as  we  have  already  seen,  Listerism  fre- 
quently wins  great  triumphs,  whilst  the  disastrous 
lack  of  Listerism,  involving  dirty  surgical  inter- 
ference and  mixed  infection,  is  the  most  disastrous 
kind  of  treatment  to  which  these  cases  can  be  sub- 
jected. But  what  if,  in  our  State  Medicine,  we  ap- 
plied the  aseptic  principle,  so  that  the  microbes 
never  reached  our  children's  brains  and  bones  and 
joints  and  bowels? 

It  is  eminently  possible,  and  merely  wants  doing. 
The  facts  are  now  known.  The  microbe  responsible 
for  the  greater  part  of  this  damage  —  and  for  a 
good  deal  more,  which  not  even  Listerism  can  alle- 
viate —  is  the  bovine  form  of  the  tubercle  bacillus. 
Some  ten  years  ago  Koch  himself,  rash  genius  that 
he  was,  announced  in  London  his  conclusion  that  the 
bovine  form  of  tubercle  bacillus  is  innocuous  to  man 
and  that  we  need,  therefore,  take  no  precautions 
against  it.  Lord  Lister  himself,  present  on  that 
occasion,  forcibly  dissented,  and  the  matter  was  put 
to  the  test  of  an  independent  Commission,  armed 
with  powers  not  to  examine  witnesses  and  follow 
their  opinion,  but  to  examine  the  facts  at  first-hand, 
and  report  what  they  found.  This  Commission, 
after  a  decade  of  admirable  work,  has  issued  its 
final  report  just  before  I  take  up  my  pen  for  this 
final  chapter,  and  in  my  argument  I  am  therefore 
armed  with  definite  evidence  the  gathering  of  which 
is  a  very  real  and  notable  service  of  Great  Britain  to 
the  civilised  world. 


380  SURGERY  AND  SOCIETY 

The  Commission's  work  may  now,  must  now,  be 
quoted  by  the  enemies  of  tuberculosis  and  the 
friends  of  every  man  everywhere.  Whether  in 
Germany  or  the  United  States  of  America,  in  France 
or  in  Australia,  the  hygienist  now  has  the  authority 
of  this  Commission's  work  behind  him  in  his  formi- 
dable struggle  against  the  vested  interests  which  ob- 
ject to  the  reforms  he  demands.  For  the  Commis- 
sion has  found  that  the  bovine  form  of  tubercle 
bacillus,  such  as  is  found  in  the  milk  and  the  flesh 
of  tuberculous  oxen,  is  capable  of  causing  disease  in 
man,  and  not  merely  "  surgical  tuberculosis  "  'so- 
called,  but  also  cases  of  phthisis  or  consumption. 
As  regards  the  meat  of  the  ox  —  and  also  as  regards 
pork,  against  which  wise  Moses  legislated  —  the  ev- 
idence is  clear,  but  the  overwhelming  weight  of  the 
indictment  falls  upon  milk,  as  many  of  us  have  been 
trying  to  persuade  the  public  for  many  years  past. 

Since  1901  the  authority  of  Koch  could  always 
be  quoted  against  us,  but  this  is  now  no  longer  pos- 
sible. The  facts  have  been  demonstrated  beyond 
all  cavil.  The  Commission  has  proved  that  the 
bovine  bacillus  does  the  damage,  and  routine  exam- 
ination of  milk  shows  that,  in  Great  Britain, 
this  bacillus  is  present  in  active  form  in  ap- 
proximately ten  per  cent,  of  all  the  samples  of  milk 
that  is  supplied  to  our  cities.  The  enormous  and 
ghastly  incidence  of  the  disease  is  thus  accounted 
for;  and  should  anyone  argue  that  there  is  not 
enough  tuberculosis  of  the  udder  in  our  herds  to  ac- 
count for  this  proportion  of  infected  milk,  the  Com- 
missioners reply  with  the  demonstration  that  a  cow 


THE  PROMISE  OF  THE  FUTURE        381 

suffering  from  tuberculosis  in  any  part  of  the  body 
other  than  the  udder  may  yet  use  her  milk  as  a  ve- 
hicle of  excretion  of  the  noxious  microbes. 

The  time  for  rational  action  has  plainly  come. 
The  few  may  protect  themselves  by  boiling  or  pas- 
teurising their  milk,  or  at  any  rate  their  children's 
milk;  or  by  purchasing  it,  at  high  cost,  from  one  of 
the  very  few  companies  which  can  be  relied  upon  not 
to  supply  tuberculous  milk.  But  only  one  measure 
will  suffice,  whether  in  this  country  or  any  other 
where  bovine  tuberculosis  exists.  We  cannot  give 
up  drinking  milk.  In  Malta  lately,  when  goats' 
milk  was  proved  to  convey  the  microbe  of  Malta 
Fever,  the  order  was  given  that  none  of  our  soldiers 
or  sailors,  stationed  there,  were  to  drink  goats'  milk 
in  the  future  —  and  the  disease  immediately  disap- 
peared. A  similar  remedy  cannot  be  applied  here, 
for  milk  is  the  most  valuable  of  foods,  above  all  for 
children.  Further,  even  boiling  and  pasteurising 
have  their  inherent  disadvantages,  and  cannot  pro- 
tect us  against  butter,  which  may  also  be  infected. 
We  must  abolish  tuberculosis  from  our  bovine  pop- 
ulation, if  we  desire  to  abolish  it  from  amongst  our- 
selves. 

The  National  Insurance  Bill,  "  for  the  prevention 
of  sickness,"  does  nothing  whatsoever  to  prevent 
this  most  common  and  deadly  disease.  Insurance, 
after  all,  is  not  prevention,  whether  in  the  case  of 
fire,  or  the  case  of  disease;  and  whilst  efficient  treat- 
ment of  pulmonary  tuberculosis  does  involve  pre- 
vention, by  greatly  reducing  infection,  nothing  will 
prevent  the  tuberculosis  due  to  the  bovine  bacillus 


382  SURGERY  AND  SOCIETY 

except  purification  of  the  milk  supply,  and  that  can 
only  be  done  by  eradicating  tuberculosis  from  our 
herds  and  keeping  them  free  from  it  ever  thereafter. 
This  will  cost  money;  and  the  objection  to  any 
kind  of  Milk  Bill  is  that  it  interferes  with  a  large 
and  powerful  vested  interest  —  but  that  cannot  be 
helped.  Britain  has  a  vested  interest  in  the  health 
of  her  people,  and  before  that  all  others  must  yield. 
When  a  question  was  lately  asked  in  Parliament  as 
to  the  possible  regular  inspection  of  our  cattle  with 
reference  to  tuberculosis,  the  answer  was  given  that 
the  consequent  aggravation  of  the  rates  would  be 
prohibitive.  To  this  most  wearisome  and  imbecile 
of  arguments  it  has  to  be  replied  that  nothing  pays 
a  country,  in  money  as  well  as  in  life,  like  efficient 
public  health  measures,  simply  because  disease  is  so 
frightfully  expensive.  The  State  is  now  undertak- 
ing to  pay,  and  pay  handsomely,  for  the  conse- 
quences of  illness  and  inefficiency.  Even  from  the 
point  of  view  of  any  Chancellor  of  the  Exchequer 
up  to  the  time  of  Mr.  Lloyd  George,  simply  look- 
ing at  the  side  of  money,  it  is  worth  while  to  inter- 
fere with  the  causes  of  disease.  At  present  rate- 
payers and  all  other  people  pay,  directly  and 
indirectly,  huge  sums  every  year  for  the  conse- 
quences of  bovine  tuberculosis,  and  as  a  much  higher 
standard  of  comfort  and  care  is  promised  for  the  ill 
and  the  unemployed  in  future,  this  sum  will  be 
greatly  raised.  Bovine  tuberculosis  is  one  of  the 
great  recruiters  of  hospital  patients,  in-door  and  out- 
door, and  whilst  these  great  institutions,  at  vast  and 
ever-increasing   expense,   yearly  seek  to  cope   with 


THE  PROMISE  OF  THE  FUTURE        383 

the  flood  of  tuberculous  patients,  they  do  nothing 
whatever  to  prevent  the  disease.  It  may  practically 
be  said  that  no  one  has  yet  done  anything  in  this 
country  to  prevent  tuberculosis  of  bovine  origin  ex- 
cept the  very  few  doctors  who  have  spent  any  time 
in  warning  the  public  and  endeavouring  to  prevent 
the  giving  of  unsterilised  milk  to  infants  and  young 
children. 

Tuberculous  animals  must  be  found  and  de- 
stroyed. There  is  nothing  else  to  be  done  with 
them  —  the  more  especially  now  we  know  that  tu- 
berculosis, elsewhere  than  in  the  udder  of  a  cow, 
may  yet  infect  her  milk.  The  owners  must  be 
compensated,  until  such  time  as  we  may  assume  that 
the  occurrence  of  tuberculosis  is  the  owner's  own 
fault  or  own  risk,  and  then  he  must  accept  the  con- 
sequences. 

Tuberculosis  is  no  more  necessary  in  cattle  than 
in  human  beings:  in  either  case  it  can  be  controlled 
by  proper  hygiene.  It  appears  that  animals  which 
live  under  natural  conditions  do  not  suffer  from  tu- 
bercle. When  they  are  cooped  up  in  ill-ventilated 
places,  then  it  appears.  What  exactly  may  be  the 
key  to  this  we  cannot  say  until  we  have  discovered 
that  part  of  the  life-history  of  the  tubercle  bacillus 
which  is  spent  outside  the  body  of  any  host.  We 
do  not  know  its  natural  reservoir,  so  to  say.  But 
already  we  can  control  its  development,  and  we 
must  do  so. 

It  is  just  as  possible  to  construct  for  cattle  as  for 
human  beings,  houses  which  are  properly  ventilated, 
properly  drained  and  properly  illuminated  by  sun- 


384  SURGERY  AND  SOCIETY 

light.  We  know  for  certain  that  exposure  to  sun- 
light and  fresh  air  very  soon  kills  the  tubercle  bacil- 
lus. I  have  seen  cow-houses,  not  far  from  London, 
so  constructed  that  the  only  possible  risk  of  tuber- 
culosis for  the  cattle,  was  from  the  expectoration  of 
their  attendants,  just  as  the  only  risk  to  the  anthro- 
poid apes  at  the  "  Zoo  "  is  from  the  expectoration 
of  the  visitors  —  and  the  glass  screens  avert  that. 
The  milk  supplied  by  these  properly  cared  for  and 
housed  cows  is  abundant  and  of  high  quality,  and 
though  at  present  it  costs  somewhat  more  than  or- 
dinary milk,  I  do  not  for  a  moment  believe  that  the 
general  supply  of  milk  produced  under  proper  con- 
ditions is  economically  impracticable.  For  a  few 
years  the  average  cost  may  be  raised :  but  the  appli- 
cations of  modern  knowledge  to  the  feeding  of  the 
cattle,  together  with  improvement  in  the  conditions 
of  transit,  should  soon  lower  the  figure  again.  Any- 
how, it  is  better  to  pay  a  little  more  for  milk  which 
contains  no  tubercle  than  a  little  less  for  milk  which 
does. 

Public  opinion  in  all  civilised  communities  must 
be  rapidly  ripened  by  the  publication  of  the  Royal 
Commission's  Report,  and  corresponding  legislation 
must  be  obtained.  We  in  Great  Britain  look  anx- 
iously and  eagerly  to  Mr.  John  Burns  and  the  Local 
Government  Board,  for  a  bold,  statesmanlike  meas- 
ure, which  shall  eradicate  the  evil  altogether. 

With  its  disappearance  —  which  I  take  to  be  a 
matter  of  less  than  a  decade  at  the  very  outside  — 
the  whole  matter  of  tuberculosis  due  to  the  bovine 
bacillus  will  disappear,  and  that  will  be  the  blessed 


THE  PROMISE  OF  THE  FUTURE        385 

end  of  Listerism  so  far  as  one  of  the  largest  fields 
of  its  present  activity  is  concerned. 

Bovine  tuberculosis  is  the  magnificent  and  urgent 
example  of  the  promise  of  the  future.  In  this  case 
we  wait  for  no  further  knowledge:  we  possess  all 
we  require  in  order  to  exterminate  the  disease  alto- 
gether. It  furnishes  a  type  of  what  we  shall  come 
to  as  regards  the  greater  part  of  the  activities  of 
Listerism.  Of  very  small  importance  relatively, 
but  still  worth  noting,  is  another  of  the  maladies  to 
which  reference  has  been  made  in  earlier  pages  for 
the  achievements  of  Listerism  in  alleviating  it.  I 
refer  to  rickets,  still  a  very  common  disease,  and  one 
which  frequently  furnishes  Listerism  with  triumphs. 
It  is  an  entirely  unnecessary  and  inexcusable  disease. 
Rickets  is  not  congenital,  but  the  post-natal  conse- 
quence of  post-natal  malnutrition.  It  will  disap- 
pear just  as  soon  as  we  rightly  rate  in  this  country 
the  products  of  our  constantly  diminishing  birth- 
rate, and  protect  children  from  the  consequences  of 
ignorance  and  neglect  —  as  I  say,  not  necessarily  on 
any  decent  grounds  of  humanity  or  sympathy,  but, 
if  you  will,  simply  because  one  cannot  have  a  soldier 
or  a  sailor  unless  one  first  has  saved  a  baby.  Above 
all,  rickets  will  disappear  when  instruction  in  the 
elements  of  infant  and  child  feeding  is  given  to  all 
girls  in  our  schools,  even  at  the  cost  of  some  inatten- 
tion to  the  particular  selection  of  fictions  commonly 
miscalled  history.  Here,  again,  the  promise  of  the 
future,  the  best  promise  that  can  be  conceived,  is 
that  there  shall  be  no  more  Listerism. 

Unlike  the  deformities  induced  by  rickets,  there 


386  SURGERY  AND  SOCIETY 

are  a  number,  of  which  clubfoot  is  the  commonest, 
which  are  due  to  causes  acting  before  birth.  Here 
Listerism  is  constantly  in  demand,  and  exceedingly 
useful.  The  causation  of  these  deformities  is  still 
unknown,  even  to  such  an  ardent  student  of  ante- 
natal pathology  as  Dr.  J.  W.  Ballantyne,  and  they 
are  correspondingly  beyond  our  control  to  prevent. 
It  is  probable  that,  for  very  many  years  to  come,  Lis- 
terism will  be  in  employment  here,  as  to-day. 

For  accidents,  and  the  deformities  due  to  acci- 
dents, Listerism  will  always  be  required,  and  the 
promise  of  the  future,  in  this  respect,  is  clearly  that 
the  possibilities  of  grafting  bone  and  muscle  and 
tendon  and  nerve  and  skin  have  not  yet  been  nearly 
exhausted.  With  the  perfection  of  his  aseptic 
technique,  the  surgeon  will  find  himself  more  and 
more  able  to  deal  with  deformities  and  accidents  in 
a  constructive  fashion.  In  cases  where,  only  a  few 
years  ago,  Listerism  did  splendidly  to  save  the  limb 
or  the  life,  at  whatsoever  cost  of  deformity  or  use- 
lessness,  surgeons  will  more  and  more  find  it  possible 
to  replace  ruined  structures  by  healthy  ones,  either 
obtained  from  one  of  the  lower  animals,  or  from 
some  human  being  who,  for  one  reason  or  another, 
can  spare  them.  The  state  of  public  and  profes- 
sional sentiment  in  Germany  and  Austria  permits 
the  making  of  experiments  in  these  directions  to  an 
extent  which  we  should  not  countenance  here,  but 
we  shall  profit  by  them  in  due  course,  nor  does  it 
follow  that  our  surgeons  are  less  skilful  or  devoted 
because  they  do  not  happen  to  lead  in  this  particular 
field. 


THE  PROMISE  OF  THE  FUTURE        387 

Syphilis  and  the  surgical  requirements  to  which  it 
leads,  together  with  its  venereal  ally,  are  definitely 
diminishing  in  Great  Britain  at  the  present  time. 
These,  being  contagious,  are  diseases  as  eminently 
preventable  as  leprosy.  It  is  a  scandal  of  the  first 
order  that  the  stupidity,  the  prudery,  the  faithless- 
ness and  the  brutal  selfishness  of  public  opinion, 
should  combine  to  prevent  the  taking  of  any  effec- 
tive measures  against  these  eminently  preventable 
evils,  one  of  which  is  the  direct  cause  demanding  so 
much  major  abdominal  surgery  in  the  case  of 
women.  I  repeat  here  the  demand  made  by  several 
of  us  in  a  deputation  to  the  Local  Government 
Board  in  191 1,  that  power  should  be  given  to  the 
authorities  for  compulsory  detention  of  persons  suf- 
fering from  these  diseases  in  certain  stages,  on  ac- 
count of  the  appalling  danger  to  the  present  and  to 
the  future.  It  is  a  farce  and  a  crime  that  we  should 
be  compelled  to  notify  measles  and  scarlet  fever, 
and  that  children  suffering  from  them  should  be 
forcibly  confined,  whilst  men  suffering  from  foul  and 
abominable  maladies  like  syphilis  and  gonorrhoea 
should  be  allowed  to  do  as  they  please  and  go  where 
they  please.  The  next  step,  most  urgently  de- 
manded in  the  interests  of  the  public  health,  is  the 
compulsory  notification  of  these  diseases  whenever 
and  wherever  they  are  diagnosed.  The  time  is  not 
far-distant  when  they  will  be  eliminated  from  the 
body-politic,  and  a  very  large  field  of  surgery,  most 
notably  that  due  to  the  infection  of  innocent  women, 
wives  and  mothers,  with  gonorrhoea,  will  henceforth 
disappear  forever. 


388  SURGERY  AND  SOCIETY 

As  regards  appendicitis,  the  state  of  pathology 
warrants  no  very  positive  statements,  nor  any  in- 
dictment of  the  public.  This  exceedingly  common 
malady  —  there  are  probably  about  40,000  cases 
annually  in  Great  Britain  —  for  which  the  surgeon 
constantly  does  so  much,  is  probably  due  to  a  very 
common,  if  not  practically  ubiquitous  microbe:  and 
why  it  should  assume  malign  activity  at  one  time  and 
not  at  another  is  more  than  we  can  yet  say.  There 
seems  to  be  real  evidence  for  the  view,  however  — 
which  were  best  expressed  not  too  precisely  —  that 
errors  in  diet  are  associated  with  the  incidence  of 
appendicitis,  though  how,  it  is  as  yet  impossible  to 
say.  No  pathologist  or  bacteriologist  would  hesi- 
tate, however,  to  assert  that  in  the  not  remote  future 
we  may  expect  to  define  the  conditions  in  which  ap- 
pendicitis arises,  and  to  state  the  dietary  precautions, 
probably  by  no  means  onerous,  which  are  necessary 
in  order  to  prevent  it.  It  is  quite  likely,  further- 
more, that  even  before  we  have  learnt  to  prevent 
appendicitis,  the  bacteriologists  will  be  able  to  pro- 
vide us  with  a  microbic  product,  of  the  nature  of  a 
vaccine  or  serum  or  antitoxin,  which  will  control  the 
inflammation  in  its  earliest  stages  and  render  the 
use  of  the  knife  superfluous. 

Whilst  the  prevention  of  disease  must  be  given 
the  forefront  in  this  chapter,  with  its  promise  that, 
over  a  great  range  of  existing  pathology,  neither  the 
knife  nor  any  other  remedy  will  in  the  coming  time 
be  called  for,  we  may  now  especially  consider  those 
developments  of  bacteriology  which  promise,  be- 
fore very  long,  to  introduce  new  remedies  for  many 


THE  PROMISE  OF  THE  FUTURE        389 

"  surgical  diseases,"  compared  with  which  even  the 
Listerian  knife  is  a  piece  of  clumsy  barbarism.  It 
has  been  granted  that  the  whole  range  of  the  sur- 
gical inflammations  are  due  to  microbes,  now  almost 
completely  identified.  Whilst  the  surgeon  has  to 
avoid  their  introduction  in  all  cases,  in  many  it  is 
their  presence  which  calls  for  his  interference.  The 
appendicitis,  or  peritonitis,  or  arthritis,  or  osteitis, 
or  what  not,  is  a  microbic  disease,  and  his  knife  is 
called  upon  either  to  drain  or  to  extirpate.  The 
purely  tuberculous  inflammations  also  come  under 
this  category. 

Now  the  very  definite  promise  of  the  bacteriolo- 
gists is  that  they  will  ere  long  be  able  to  provide  us 
with  specific  chemical  remedies  which  will  carry  all 
these  maladies  over  into  the  realm  of  medicine 
again,  and  leave  the  surgeon's  knife  unrequested. 
In  some  cases,  as  is  suggested  by  the  use  of  "  Sal- 
varsan  "  or  "  606  "  in  syphilis,  chemistry  may  elabo- 
rate substances  which  kill  the  peccant  parasites  out- 
right, leaving  the  body  the  very  simple  task  of 
"  cleaning  up  the  mess,"  and  affording  no  opportu- 
nity at  all  for  the  surgeon.  In  other  cases,  it  may 
be  an  antitoxin  which  supplies  the  need.  Thus,  to 
consider  what  has  been  already  accomplished,  the 
introduction  of  diphtheria  antitoxin  has  reduced, 
probably  by  hundreds  of  thousands  of  cases  annu- 
ally, the  number  of  instances  in  which  the  surgical 
operation  called  tracheotomy  is  required.  Form- 
erly, any  case  of  diphtheria  might,  in  a  few  hours, 
reach  the  point  at  which  only  the  opening  of  the 
windpipe  or  trachea  would  permit  the  patient  any 


39Q  SURGERY  AND  SOCIETY] 

longer  to  breathe.  Nowadays  the  antitoxin,  in  uni- 
versal employment,  controls  the  disease  so  efficiently 
that  the  surgeon's  knife  is  required  only  in  cases 
which,  for  one  reason  or  another,  have  been  neg- 
lected. Listerian  tracheotomy  is  a  very  fine  thing, 
and  has  saved  a  multitude  of  little  lives,  but  obvi- 
ously the  diphtheria  antitoxin  is  better  still. 

Some  similar  product  may  at  any  moment  give 
us  the  control  of  surgical  and  all  other  forms  of  tu- 
berculosis, even  before  the  disease  is  altogether  pre- 
vented, which  is  the  ideal  and  immediately  feasible 
way  of  dealing  with  it. 

For  many  years  past,  sera  have  been  prepared 
from  the  commoner  agents  of  surgical  inflamma- 
tion, the  staphylococcus  and  the  streptococcus;  and 
many  observers  have  reported  well  of  their  use  in 
puerperal  fever,  peritonitis,  erysipelas  and  other 
surgical  conditions.  None  of  these  sera,  however, 
have  approached  the  efficacy  of  the  antitoxin  in  the 
case  of  the  diphtheria  bacillus,  and  there  are  evi- 
dently many  subtleties  of  chemistry  to  be  unravelled 
before  a  completely  satisfactory  method  of  dealing 
with  these  organisms  can  be  obtained.  But  it  cer- 
tainly will  be  obtained,  and  may  be  granted  us  at 
any  moment.  The  field  of  Listerism  will  thereupon 
be  more  severely  restricted  than  ever.  The  whole 
range  of  the  surgical  inflammations,  from  appendi- 
citis downwards,  will  become  "  medical  diseases  " 
once  more,  and  will  be  rapidly  and  safely  controlled 
by  appropriate  doses  of  medicine  of  a  new  kind, 
elaborated  by  the  bacteriologist  in  his  laboratory. 


THE  PROMISE  OF  THE  FUTURE        391 

But  though  the  knife  will  remain  unused,  Pasteur 
and  Lister,  who  taught  us  what  inflammation  is,  will 
be  healing  there  also. 

It  may  now  be  taken  as  practically  certain  that 
cancer  is  not  a  microbic  disease.  The  malignant 
tumours,  including  cancer  and  sarcoma,  still  defy 
elucidation,  as  do  their  innocent  allies.  For  these 
latter,  in  especial,  such  as  the  fibro-muscular  tumours 
of  the  uterus,  fatty  tumours  and  so  forth,  it  is  prob- 
able that  Listerism  will  be  required  for  not  a  few 
years  yet  to  come.  The  chemical  conditions  of  their 
development  are  yet  far  beyond  our  elucidation,  and, 
therefore,  far  beyond  our  control.  But  as  regards 
the  malignant  tumours,  for  which  Listerism  is  now 
rightly  more  employed  than  ever  heretofore,  the 
prospect  is  extremely  hopeful,  and  at  any  time  the 
discovery  may  be  made  which  will  forever  banish 
the  knife  from  this  field.  The  public  opinion  that 
there  is  something  peculiarly  hopeless  about  the 
problem  of  cancer  is  not  shared  by  experts.  So 
much  definite  progress  has  been  made  within  the  past 
decade  that  the  time  can  scarcely  be  far  distant 
when  the  knife  will  be  rendered  superfluous  by  the 
introduction  of  chemical  substances  in  the  presence 
of  which  malignant  cells  cannot  live. 

The  key  to  the  solution  of  this  problem,  as  I  have 
maintained  for  many  years,  is  to  be  found  in  the 
chemistry  of  those  human  or  animal  patients  in 
whom  there  occurs  spontaneous  recovery  from  ma- 
lignant growths.  If  these  cases  be  adequately 
studied,  the  solution  of  the  problem  must  be  found. 


392  SURGERY  AND  SOCIETY 

Hitherto,  however,  they  have  been  too  much  re- 
garded as  merely  curiosities,  which  did  not  demand 
the  help  of  the  surgeon,  and  were,  therefore,  of  no 
further  interest  to  him. 

Meanwhile,  though  at  any  moment  the  whole 
aspect  of  the  question  may  be  changed,  it  is  the  duty 
of  all  who  write  for  the  public  eye  on  this  subject 
to  insist  that  the  earliest  possible  recourse  to  Lister- 
ism  offers  the  best  hope  in  all  cases  of  cancer;  and 
any  reader  who  will  consult  the  pages  of  Mr. 
Childe's  book,  referred  to  in  my  opening  chapter, 
will  realise  that  modern  Listerism  accomplishes  very 
great  things  in  this  field.  May  the  day,  neverthe- 
less, soon  dawn,  when  Listerism  is  banished  from  it 
forever. 

It  will  be  plain  to  the  reader  that,  with  the  intro- 
duction of  an  efficient  chemical  antidote  to  cancer, 
and  of  anti-sera  and  similar  bodies  for  microbic  in- 
fection, the  field  of  Listerism  in  the  future  will  be 
enormously  contracted.  To  anyone  who  has  any 
idea  of  the  subtlety  and  delicacy  of  the  living  body 
and  of  the  living  cells  of  which  it  is  composed,  even 
the  cleanest  knife  must  appear  a  brutal  and  barbaric 
instrument.  It  is  bio-chemistry,  or  the  chemistry  of 
life,  which  will  yearly  make  this  more  clear,  mean- 
while giving  us  more  and  more  control  over  vital 
processes  in  all  their  stages.  The  remoter  promise 
of  the  future  thus  excludes  the  knife  altogether  from 
the  armamentarium  of  the  healing  art,  except  in 
cases  of  accident. 

But  even  when  we  have  relegated  the  knife  to 


THE  PR  i  OF  THE  FUTURE        393 

museums,  and  when  battle-fields  are  no  more,  Lister- 
ism  will  still  be  in  nightly  and  daily  demand  for  its 
unique  and  irreplaceable  services  to  motherhood. 
There  is  no  inherent  reason  why  the  bio-chemistry 
of  the  future  should  not  control  death  altogether  — 
though  whether  that  were  worth  doing  is  another 
question.  Meanwhile  there  will  always  be  need  of 
births,  and  wherever  a  new  human  life  comes  into 
the  world,  there  Listerism  will  guard  the  portals, 
protecting  mother  and  child  alike. 

Sociologically,  then,  I  would  say  that  the  promise 
of  the  future  is  for  the  access  of  Listerian  protec- 
tion to  all  motherhood.  The  reader  must  pardon 
my  insistent  return,  as  a  Eugenist,  to  this  subject  in 
my  closing  pages.  Radical  progress,  which  means 
racial  progress,  in  the  future  can  only  be  assured 
through  parenthood.  The  nineteenth  century  did 
well,  in  many  ways,  for  external  conditions,  and  for 
the  amplification  of  man's  power  upon  external 
things.  The  eugenic  century  must  deal  with  man 
himself,  and  so  long  as  man  is  mortal,  this  means 
that  it  must  work  primarily  through  parenthood  and 
the  conditions  of  parenthood.  Those  who  believe 
this  will  repeat  it  so  persistently  that  at  last  people 
will  begin  to  think  that  they  have  thought  it  for 
themselves,  and  then  we  shall  get  what  we  demand. 
Notwithstanding  all  the  efforts  of  the  patriots  and 
the  pamphleteers  and  the  pulpit  orators  and  the 
press,  the  birth-rate  will  persistently  fall,  not  alone, 
as  I  am  now  inclined  to  suspect,  from  purely  voli- 
tional causes.     The  only  remedy  will  be  to  attend 


394  SURGERY  AND  SOCIETY 

more  scrupulously  to  such  mothers  and  babies  as  we 
have:  and  the  first  demand  is  the  certain  and  com- 
plete provision  of  expert  modern  Listerism  for 
every  mother  in  the  land,  high  or  low,  young  or  old, 
married  or  unmarried.  Incidentally  we  shall  abol- 
ish perhaps  one-third  of  all  the  nation's  blindness, 
and  even  that  great  boon  will  be  the  least  of  it. 
Puerperal  fever  will  wholly  disappear,  when  all 
mothers  are  properly  looked  after  for  at  least  a 
month  before  confinement,  during  confinement,  and 
for  a  fortnight  or  so  thereafter.  A  vast  amount  of 
present-day  Listerism,  which  concerns  itself  with  the 
"  diseases  of  women,"  will  be  no  longer  in  request 
when  Listerism  is  rightly  available  at  woman's  great 
crisis.  Indirectly  the  rate  of  infant  mortality  will 
be  reduced,  and  the  initial  stages  of  post-natal  life 
on  the  part  of  the  survivors  will  be  safeguarded, 
with  permanently  satisfactory  results. 

In  no  country  in  the  world  are  these  conditions 
even  approximately  established,  but  if  modern  civili- 
sation is  to  survive  against  the  internal  causes  of  its 
degeneration,  it  must  establish  such  conditions,  well 
realising  that  the  mothers  are  necessarily  the  first 
charge  upon  the  resources  of  any  nation  that  is  to 
endure. 

Here,  then,  our  account  may  end.  I  have  en- 
deavoured to  set  forth  the  remarkable  history  of 
Listerism,  and  to  indicate  its  past  and  present  serv- 
ices to  the  world;  and  finally,  to  herald  those 
imminent  advances  of  science,  preventive  and  cura- 
tive, which  will  substantially  supersede  any  occasion 


THE  PROMISE  OF  THE  FUTURE         395 

for  Listerism  whatever,  except  in  the  noblest  task 
to  which  this  or  any  other  form  of  knowledge  or 
power  can  be  called  —  that  of  serving  those  who 
give  birth  to  the  life  of  this  world  to  come. 


FINIS 


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